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HX641 43627 
RC566.B541920    The  narcotic  drug  pr 


RECAP 


1^  i|)[ifl!ti"':,:  „ 

m 


Columbia  ©nibersitp 

in  tfje  €itv  of  ^etu  gork 

COLLEGE  OF  PHYSICIANS 
AND   SURGEONS 


Reference  Library 

Given  by 


THE    NARCOTIC    DRUG 
PROBLEM 


BY 

ERNEST  S.  BISHOP,  M.D.,  F.A.C.P. 

Clinical  Professor   of  Medicine,   New  York  Polyclinic  Medical  School; 

Member  Narcotic  Committee,  Conference  of  Judges  and  Justices 

of  New  York  State;  Committee  on  Habit  Forming:  Drugs, 

Section  on  Food  and  Drugs,  American  Public 

Health  Association. 

Formerly  Resident  Physician,  Alcoholic,  Narcotic  and  Prison  Service, 
Bellevue  Hospital ;  Formerly  Visiting  Physician  and  President  of 
the  Medical  Board,  Workhouse  Hospital,  New  York  Department 
of  Corrections;  Fellow  Academy  of  Medicine,  Visiting 
Physician  St.  Joseph  Tuberculosis  Hospital,  Con- 
sulting Physician  to  St.  Mark's  Hospital, 
etc.,  etc. 


THE  MACMILLAN  COMPANY 

1920 

All  rights  reserved 


COPTRIGHT,  1920 
BT  THE  MACMILLAN  COMPANY 


Set  up  and  electrotyped.     Published  January,  1920. 


TO 

MY   WIFE, 


WHO  HAS  SHARED    MY    BURDENS  AND  HELPED  I» 
MY  WORK,   AND    WHOSE    INTEREST    IN    AND  SYM- 
PATHY WITH   MY   WORK    HAS    MADE  MUCH  OF  IT 
POSSIBLE, 
THIS  BOOK  IS  INSCRIBED. 


PREFACE 

This  book  has  been  prepared  in  response  to  a  growing 
demand  that  the  author  group  together  under  one  cover 
some  of  the  material  collected  out  of  a  varied  experience 
with  many  aspects  and  phases  of  narcotic  drug  addiction, 
and  with  activities  in  the  attempted  solution  of  its  prob- 
lems. 

Some  of  this  experience  has  been  previously  presented  in 
many  addresses  before  scientific  and  other  societies  and 
in  articles  in  the  medical  press. 

The  author  is  not  associated  with  nor  interested  in  any 
hospital  or  institution  active  in  the  care  of  these  cases  for 
financial  return  or  pecuniary  benefit.  He  is  not  the  ex- 
ponent or  mouthpiece  or  proponent  of  any  special  or  spe- 
cific "  remedy  "  or  "  treatment  "  or  method  of  so-called 
"  cure."     He  has  no  axe  to  gxind. 

He  is  not  a  "  specialist "  in  the  treatment  of  narcotic 
drug  addiction.  He  is  a  practitioner  of  diagnostic  and 
clinical  medicine,  in  whose  professional  work  the  care  of 
the  narcotic  addict  has  constituted  much  the  smaller  part 
of  his  activities  and  studies,  and  that  part  has  been  largely 
carried  on  without  recompense  and  often  at  his  personal  ex- 
pense. 

Some  years  ago,  through  hospital  affiliations  a*nd  duties, 
the  writer  was  brought  to  face  this  problem  of  opiate  ad- 
diction and  after  a  while  saw  in  it  very  important  and  very 
interesting  clinical  problems  of  physical  disease  and  phys- 
ical reactions  upon  which  he  made  observations  and  studies. 

Hospital  connections  and  the  publishing  of  various  ar- 
ticles have  since  that  time  brought  him  into  association 
with  practically  all  phases  and  aspects  of  activity  in  the 


PKEFACE 

consideration  and  handling  of  the  narcotic  drug  problem. 
He  has  listened  to  discussions  of  the  subject  by  promoters ; 
by  reformers  of  various  sorts;  by  those  engaged  in  legis- 
lative, judiciar}^,  administrative,  custodial,  penological, 
sociological,  psychological  or  psychiatrical,  medical  and 
other  lines  of  work,  and  by  narcotic  addicts  from  all  classes 
and  types  of  people  and  their  friends  and  relatives,  etc., 
in  groups,  or  as  individuals. 

Two  vital  elements  seem  to  the  author  to  have  received 
insufficient  consideration  in  the  efforts  to  solve  the  narcotic 
drug  problem.  One  of  these  elements  is  the  sufferings  and 
struggles  and  problems  of  the  narcotic  addict,  *and  the  other 
is  the  nature  of  the  physical  disease  with  which  he  is  af- 
flicted. 

This  book  is  an  effort  to  accomplish  two  things,  first  to 
present  the  two  elements  above  stated,  and  second  to  out- 
line, discuss  and  correlate  various  elements  and  conflicting 
activities  so  that  each  of  us  can  appreciate  the  relation  of 
his  own  endeavor  to  the  whole  narcotic  drug  problem,  can 
realize  the  comparative  importance  of  his  own  observations, 
and  can  cooperate  with  the  others  for  the  benefit  of  hu- 
manity, for  the  welfare  of  society  and  posterity  and  for 
the  increased  health  and  happiness  and  economic  useful- 
ness of  the  individual. 


CONTENTS 

CHAPTER  PAOE 

Preface .     .     •.     r.     ..     .    vii 

I.    Inteoduction .    >      1 

II.     Fundamental  Considerations 11 

III.  The  Nature  of  Narcotic  Drug  Addiction- 

Disease     23 

IV.  The  Mechanism  of  Narcotic  Drug  Addiction- 

Disease     35 

Y.    Remarks  on  Methods  of  Treating  Narcotic 

Drug  Addiction 50 

VI.    The  Eational  Handling  of  Narcotic  Drug 

Addiction-Disease 61 

VII.    Eelation  of  Narcotic  Drug  Addiction  to  Sur- 
gical Cases  and  Intercurrent  Diseases  .     85 

VIII.    Laws,   and   Their   Eelations   to    Narcotic 

Drugs 95 

IX.    Some  Comments  Upon  the  Legitimate  Use  of 

Narcotics  in  Peace  and  War 114 

X.     General  Survey  of  the  Situation  and  the 

Need  of  the  Hour 122 

Appendix  :  Human  Documents, —  State- 
ments OF  Sufferers  from  Narcotic  Drug 
Addiction-Disease 137 


THE  NARCOTIC  DRUG  PROBLEM 


CHAPTEE  I 

INTEODTJCTION 

It  is  a  fact  becoming  more  and  more  obvious  tbat  too 
little  study  and  effort  to  interpret  their  physical  condition 
have  been  given  to  those  unfortunates  suffering  from 
narcotic  drug  addiction. 

We  have  neglected  their  disease  in  its  origin  and  sub- 
sequent progress  and  formed  our  conception  of  its  char- 
acter from  fully  developed  conditions  and  spectacular  end- 
results.  We  have  seen  some  of  them  during  or  after  our 
fruitless  efforts  at  treatment,  their  tortures  and  poor 
physical  condition  overcoming  their  resolutions,  until  they 
plead  for  and  attempted  to  obtain  more  of  their  drug. 
We  have  seen  others  exhausted,  starved,  with  locked-up 
elimination,  toxic  from  self-made  poisons  of  faulty  metab- 
olism, worn  with  the  struggle  of  concealment  and  hope- 
less resistance,  and  for  the  time  being  more  or  less  irre- 
sponsible beings,  made  so,  not  because  of  their  addiction- 
disease  itself,  but  because  they  were  hopeless  and  discour- 
aged and  did  not  know  which  way  to  turn  for  relief. 

What  literature  has  appeared  on  the  subject  has  usually 
pictured  them  as  weak-minded,  deteriorated  wretches, 
mental  and  moral  derelicts,  pandering  to  morbid  sensual- 
ity; taking  a  drug  to  soothe  them  into  supposed  dream 
»  states  and  give  them  languorous  delight ;  held  by  most  of 
us  in  dislike  and  disgust,  and  regarded  as  so  depraved  that 
their  rescue  was  impossible  and  they  unworthy  of  its  at- 
tempt. 

1 


2  THE  NARCOTIC  DRUG  PROBLEM 

We  have  overlooked,  ignored  or  misinterpreted  intense 
physical  agony  and  symptomatology,  and  regarded  failure 
to  abstain  from  narcotics  as  evidence  of  weak  will-power 
or  lack  of  desire  to  forego  supposed  morbid  pleasure.  We 
have  prayed  over  our  addicts,  cajoled  them,  exhorted  them, 
imprisoned  them,  treated  them  as  insane  and  made  them 
social  outcasts ;  either  refused  them  admission  to  our  hos- 
pitals or  turned  them  out  after  ineffective  treatment  with 
their  addiction  still  fastened  to  them.  To  a  great  extent 
the  above  has  been  their  experience  and  history. 

In  great  numbers  they  have  realized  our  failure  to  ap- 
preciate their  condition  and  to  remedy  it,  and  have  after 
desperate  trials  of  quacks,  charlatans  and  exploited 
"  cures,"  finally  accepted  their  slavery  and  by  regulation 
of  their  drug  and  life,  their  addiction  unsuspected,  main- 
tained a  socially  and  economically  normal  existence. 
Some  failing  in  this,  perhaps  broken  and  impoverished, 
their  addiction  recognized,  have  become  social  and  eco- 
nomic derelicts  and  often  public  charges. 

From  these  last,  together  with  the  addicted  individuals 
from  the  class  of  the  fundamentally  unfit,  we  have  painted 
our  addiction  picture.  Confined  and  observed  by  the 
custodial  official  and  the  doctor  of  the  institution  of  cor- 
rection and  restraint,  or  concealed  as  family  skeletons  in 
many  homes^  descriptions  of  them  have  given  to  the 
narcotic  addicts  as  a  whole  their  popular  status  —  cases 
of  mental  and  moral  disorder  due  to  supposed  drug  action 
or  habit  deterioration,  and  based  upon  inherent  lack  of 
mental  and  moral  stamina. 

It  was  with  the  above  conception  of  these  addiction  con- 
ditions that  I  began  my  work  in  the  Alcoholic,  Narcotic 
and  Prison  Service  of  Bellevue  Hospital,  attracted  to 
the  service  not  by  hope  of  helping  nor  by  interest  in 
"  jags  "  and  "  dope  fiends ''  as  I  then  considered  them, 
but  by  the  mass  of  clinical  material  available  for  surgical 
and  medical  diagnosis  and  study  which  was  daily  admitted 


INTRODUCTION  3 

to  those  wards.  When  I  left  the  service  after  sixteen 
months  of  day  and  night  observation,  with  personal  over- 
sight and  attempt  to  care  for  in  the  neighborhood  of  a 
thousand  admissions  a  month,  my  early  and  faulty  concep- 
tion of  narcotic  addicts  was  replaced  by  a  settled  convic- 
tion that  these  cases  were  primarily  medical  problems.  I 
realized  that  these  patients  were  people  sick  of  a  definite 
disease  condition,  and  that  until  we  recognized,  under- 
stood and  treated  this  condition,  and  removed  the  stigma 
of  mental  and  moral  taint  from  those  cases  in  which  it 
did  not  exist,  we  should  make  little  headway  towards  solu- 
tion of  the  problem  of  addiction. 

It  is  a  fact  that  the  narcotic  drugs  may  afford  pleas- 
urable sensations  to  some  of  those  not  yet  fully  addicted 
to  them,  and  that  this  effect  has  been  sought  by  the  ment- 
ally and  morally  inferior  purely  for  its  enjoyment  for  the 
same  reasons  and  in  the  same  spirit  that  individuals  of 
this  type  tend  to  yield  themselves  to  morbid  impulses, 
curiosities,  excesses  and  indulgences.  Experience  does 
not  teach  them  intelligence  in  the  management  of  opiate 
addiction  and  they  tend  to  complicate  it  with  cocaine  and 
other  indulgence,  increasing  their  irresponsibility  and 
conducing  to  their  earlier  self -elimination. 

Wide  and  varied  experience,  however,  hospital  and 
private,  with  careful  analysis  of  history  of  development, 
and  consideration  of  the  individual  case,  demonstrates  the 
fact  that  a  majority  of  narcotic  addicts  do  not  belong  tq 
this  last  described  type  of  individuals.  It  will  be  found 
upon  careful  examination  that  they  are  average  individuals 
in  their  mental  and  moral  fundamentals.  Among  them 
are  many  men  and  women  of  high  ideals  and  worthy  ac- 
complishments, whose  knowledge  of  narcotic  administra- 
tion was  first  gained  by  "  withdrawal "  agonies  following 
cessation  of  medication,  who  have  never  experienced  pleas- 
ure from  narcotic  drug,  are  normal  mentally  and  morally, 
and  unquestionably  victims  of  a  purely  physical  affliction. 


4  THE  NARCOTIC  DRUG  PROBLEM 

The  neurologist,  the  alienist,  the  psychologist,  the  law- 
maker, the  moralist,  the  sociologist  and  the  penologist  have 
worked  in  the  field  of  narcotic  addiction  in  the  lines  of 
their  special  interests,  and  interpreted  in  the  lights  of  their 
special  experiences.  Each  has  reported  conditions  and  re- 
sults as  he  saw  them,  and  advised  remedies  in  accordance 
with  his  understanding.  With  very  few  exceptions  little 
has  been  heard  from  the  domain  of  clinical  medicine  and 
from  the  internist.  It  is  only  here  and  there  that  the 
practitioner  of  internal  medicine  has  been  sufficiently  in- 
spired by  scientific  interest  to  seriously  consider  narcotic 
drug  addiction  and  to  make  a  clinical  study  of  its  actual 
physical  manifestations  and  phenomena. 

The  idea  that  narcotic  drug  addiction  should  be  ac- 
corded a  basis  of  weakness  of  will  —  neurotic  or  otherwise, 
inherent  or  acquired  —  and  should  be  classed  as  a  mor- 
bid appetite,  a  vice,  a  depraved  indulgence,  a  habit,  has 
been  generally  unquestioned  and  the  prevailing  dogma  for 
many  years.  It  is  very  unfortunate  that  we  have  paid  so 
little  attention  to  material  facts  and  have  made  so  little 
effort  to  explain  constant  physical  symptomatology  on  a 
basis  of  physical  cause,  and  that  there  has  not  been  a 
wider  recognition  and  more  general  acceptation  of  scien- 
tific work  that  has  been  done. 

Despite  the  years  of  effort  that  have  been  devoted  to 
handling  the  narcotic  addict  on  the  basis  of  inferiority  and 
neurotic  tendencies,  and  of  weakness  of  will  and  perverted 
appetite  —  in  spite  of  exhortation,  investigation,  law-mak- 
ing and  criminal  prosecution  —  in  spite  of  the  various 
specific  and  special  cures  and  treatments  —  narcotic  ad- 
diction has  increased  and  spread  in  our  country  until  it 
has  become  a  recognized  menace  calling  forth  stringent 
legislation  and  desperate  attempts  at  administrative  and 
police  control.  And  though  a  large  amount  of  money  has 
been  spent  in  custodial  care  and  sociological  investigation 
on  the  prevailing  theories,  and  in  various  legislation,  much 


INTRODUCTION  5 

of  it  necessary  and  mucli  of  it  wisely  planned,  we  have 
made  but  little  progress  in  tlie  real  remedy  of  conditions. 

It  is  becoming  apparent  that  in  spite  of  all  the  work 
which  has  been  done  —  in  spite  of  all  the  efforts  which 
have  been  made  —  there  has  been  practically  no  change  in 
the  general  situation,  and  there  has  been  no  solution  of 
the  drug  problem. 

In  analyzing  results  of  efforts  and  arriving  at  causes 
for  failure,  it  seems  to  me  that  it  is  always  wise  to  begin 
at  the  beginning,  and  to  ask  ourselves  whether  we  have 
not  started  out  with  an  entirely  erroneous  conception  of 
our  basic  problem.  Is  it  not  possible  that  instead  of 
punishing  a  supposedly  vicious  man,  instead  of  restraining 
and  mentally  training  a  supposedly  inherent  neuropath 
and  psychopath,  we  should  have  been  treating  an  actually 
sick  man  ?  Is  it  not  possible  that  the  addict  did  not  want 
his  drug  because  he  enjoyed  it  but  that  he  wanted  it  be- 
cause his  body  required  it  ?  This  is  not  only  possible  — 
it  is  fact  —  and  the  whole  secret  of  our  failure  has  been 
the  misconception  of  our  problem  based  on  our  lack  of 
understanding  of  the  average  narcotic  drug  addict  and  his 
physical  conditions. 

In  my  own  experience  as  a  medical  practitioner  I  know 
that  non-appreciation  of  this  fact  was  the  cause  of  my 
early  failures;  and  I  further  know  that  from  the  begin- 
ning of  appreciation  of  this  fact  dates  whatever  progress 
I  have  made  and  whatever  success  I  have  attained.  In 
my  early  efforts  as  Eesident  Physician  to  the  Alcoholic 
and  Prison  Wards  of  Bellevue  Hospital,  devoid  of  previ- 
ous experience  in  the  treatment  of  narcotic  addiction, 
directed  by  my  available  literature  and  by  the  teachings 
of  those  in  my  immediate  reach,  I  followed  the  accepted 
methods.  I  tried  the  methods  of  the  alienist ;  I  tried  the 
exhortations  of  the  moralist;  I  tried  sudden  deprivation 
of  the  drug ;  I  tried  rapid  withdrawal  of  the  drug ;  I  tried 
slow  reduction  of  the  drug;  I  tried  well-known  special 


6  THE  NARCOTIC  DRUG  PROBLEM 

"  treatment."  In  other  words  I  exhausted  the  methods 
of  handling  narcotic  drug  addiction  of  which  I  knew.  My 
results  were,  in  these  early  efforts,  one  or  two  possible 
"  cures,''  but  as  a  whole  suffering  and  distress  without 
relief ;  in  a  word  failure. 

The  blame  I  placed  not  where  it  belonged  —  on  the 
shoulders  of  my  medical  inefficiency  and  lack  of  apprecia- 
tion and  knowledge  of  the  disease  I  was  treating  —  but 
upon  what  I  supposed  was  my  patient's  lack  of  co-opera- 
tion and  unwillingness  to  forego  what  I  supposed  to  be 
the  joys  of  his  indulgence.  In  discouragement  and  de- 
spair I  held  the  addict  to  be  a  degenerate,  a  deteriorated 
wretch,  unworthy  of  help,  incurable  and  hopeless. 
Strange  as  it  seems  to  me  now,  possessing  as  I  did  good 
training  in  clinical  observation  and  being  especially  in- 
terested in  clinical  medicine,  in  calm  reliance  upon  the 
correctness  of  the  theories  I  followed,  I  ignored  the  pres- 
ence of  obvious  disease. 

As  to  the  existing  opinion  that  the  addict  does  not  want 
to  be  cured,  and  that  while  under  treatment  he  cannot  be 
trusted  and  will  not  co-operate,  but  will  secretly  secure 
and  use  his  drug  —  I  can  only  quote  from  my  personal 
experience  with  these  cases.  During  my  early  attempts 
with  the  commonly  known  and  too  frequently  routinely 
followed  procedures  of  sudden  deprivation,  gradual  reduc- 
tion and  special  or  specific  treatment,  etc.,  my  patients  be- 
ginning with  the  best  intentions  in  the  world,  often  tried 
to  beg,  steal  or  get  in  any  possible  way  the  drug  of  their 
addiction.  Like  others,  I  placed  the  blame  on  their  sup- 
posed weakness  of  will  and  lack  of  determination  to  get 
rid  of  their  malady.  Later  I  realized  the  fact  that  the 
blame  rested  almost  entirely  upon  the  shoulders  of  my 
medical  inefficiency  and  my  lack  of  understanding  and 
ability  to  observe  and  interpret.  The  narcotic  addict  as 
a  rule  will  co-operate  and  will  suffer  if  necessary  to  the 
limit   of  his  endurance.     Demanding  co-operation   of   a 


INTRODUCTION  7 

completely  developed  case  of  opiate  addiction  during  and 
following  incompetent  withdrawal  of  the  drug  is  asking 
a  man  to  co-operate  for  an  indefinite  period  in  his  own 
torture.  There  is  a  well-defined  limit  to  every  one's  power 
of  endurance  of  suffering. 

Abundant  evidence  of  what  I  have  written  is  easily 
found  among  the  many  sufferers  from  the  disease  of 
opiate  addiction  who  have  maintained  for  years  a  per- 
sonal, social  and  economic  efficiency  —  their  affliction  un- 
known and  unsuspected.  These  cases  are  not  widely 
known  but  there  are  a  surprising  number  of  them.  When 
one  of  them  becomes  known  his  success  in  handling  his 
condition  and  its  problems  is  generally  attributed  to  his 
being  on  a  rather  higher  moral  and  mental  plane  than  his 
fellow  sufferers  and  possessed  of  will-power  sufficient  to 
resist  temptation  to  over-indulge  his  so-called  appetite. 
We  have  not  as  a  rule  considered  any  other  explanation 
nor  sought  more  at  length  for  the  cause  of  his  apparent 
immunity  to  the  hypothetical  opiate  stigmata.  It  would 
have  been  wiser  and  more  profitable  for  us  to  have  re- 
spectfully listened  to  his  experiences  and  learned  some- 
thing about  his  disease. 

The  facts  in  such  cases  are  that  instead  of  being  men  of 
unusual  stamina  and  determination,  they  are  simply  men 
who  have  used  their  reasoning  ability.  They  have  tried 
various  methods  of  cure  without  success.  They  have 
realized  the  shortcomings  and  inadequacy  of  the  usual 
imder standing  and  treatment  of  their  condition.  Being 
average  practical  men,  and  making  the  best  of  the  in- 
evitable, they  have  made  careful  and  competent  study  of 
their  own  cases  and  have  achieved  sufficient  familiarity 
with  the  actions  of  their  opiate  upon  them  and  their  re- 
actions to  the  opiate  to  keep  themselves  in  functional  bal- 
ance and  competency  and  control.  The  success  of  these 
people  is  not  due  to  determined  moderation  in  the  in- 
dulgence of  a  morbid  appetite.     It  is  due  to  their  ability 


8  THE  NARCOTIC  DRUG  PROBLEM 

to  discover  facts;  to  their  wisdom  in  tlie  application  of 
common-sense  to  what  they  discover;  and  to  rational  pro- 
cedure in  the  carrying  out  of  conclusions  reached  through 
their  experiences.  They  have  simply  learned  to  manage 
their  disease  so  as  to  avoid  complications.  When  I  tried 
to  account  for  some  of  the  things  I  saw  by  questioning 
these  men  who  had  studied  and  learned  upon  themselves, 
I  soon  obtained  a  clearer  conception  of  what  opiate  addic- 
tion was. 

When  we  eliminate  the  distracting  and  misleading  com- 
plications, mental  and  physical,  and  study  the  residue  of 
physical  symptomatology  left,  we  make  some  very  surpris- 
ing and  striking  observations. 

We  find  that  we  are  dealing  fundamentally  with  a  defin- 
ite condition  whose  disease  manifestations  are  not  in  any 
way  dependent  in  their  origin  upon  mental  processes,  but 
are  absolutely  and  entirely  physical  in  their  production, 
and  character.  These  symptoms  and  physical  signs  are 
clearly  defined,  constant,  capable  of  surprisingly  accurate 
estimation,  yielding  with  a  sureness  almost  mathematical 
in  their  response  to  intelligent  medication  and  the  recogni- 
tion and  appreciation  of  causative  factors;  forming  a 
clean-cut  symptom-complex  peculiar  to  opiate  addiction. 
Any  one  —  whether  of  lowered  nervous,  mental  and  moral 
stamina,  or  a  giant  of  mental  and  physical  resistance  — 
will,  if  opiates  are  administered  in  continuing  doses  over 
a  sufficient  length  of  time,  develop  some  form  of  this 
symptom-complex.  It  represents  causative  factors,  and 
definite  conditions  which  are  absolutely  and  entirely  du0 
to  changed  physical  processes  which  fundamentally  un- 
derlie all  cases  of  opiate  addiction,  and  which  proceed  to 
full  development  through  well-marked  stages. 

During  the  past  years  I  have  had  under  my  care  a  num- 
ber of  excellent  and  competent  physicians  of  unusual 
mental  and  nervous  balance  and  control  in  whom  there 
could  be  no  hint  of  lack  of  courage,  nor  of  deficient  will- 


INTRODUCTION  9 

power,  nor  of  lack  of  desire  to  be  free  from  their  afflic- 
tion. Possessing,  some  of  them,  unusual  medical  training 
and  scientific  ability,  having  added  to  this  the  actual  ex- 
periences of  opiate  addiction,  they  with  others  have  co^ 
operated  and  aided  in  experiment,  study  and  analysis, 
and  the  result  has  been  in  their  minds  as  in  mine,  com-' 
plete  confirmation  of  the  facts  above  stated. 

Primarily,  there  are  two  phrases  I  should  like  to  see 
eliminated  from  the  literature  of  opiate  drug  addiction. 
I  believe  they  have  worked  great  injustice  to  the  opiate 
addict  and  have  played  no  small  part  in  the  making  of 
present  conditions.  It  seems  to  me  that  to  speak  and 
write  as  we  still  often  do  of  "  drug  habit ''  and  ''  drug 
fiends  "  is  placing  upon  the  opiate  addict  a  burden  of 
responsibility  which  he  does  not  deserve.  If  long  ago  we 
had  discarded  the  word  "  habit "  and  substituted  the  word 
"  disease  ''  I  believe  we  would  have  saved  many  people 
from  the  hell  of  narcotic  drug  addiction.  I  believe  if  it 
had  not  been  for  the  use  of  the  word  "  habit "  that  the 
medical  profession  would  long  ago  have  recognized  and  in- 
vestigated this  condition  as  a  disease.  A  man,  physician 
or  layman,  believes  that  he  can  control  a  habit  when  he 
would  fear  the  development  of  a  disease.  Until  now, 
however,  the  description  has  been  "  drug  habit.'^  And  the 
man  who  acquires  one  of  the  most  terrible  diseases  to  be 
encountered  in  the  practice  of  medicine  is  unconscious  of 
his  being  threatened  with  a  physical  disease  process  un- 
til this  process  has  become  so  developed  and  so  rooted 
that  it  is  beyond  average  human  power  to  resist  its  physical 
demands. 

In  the  near  future,  I  earnestly  hope  the  true  story  and 
the  real  facts  concerning  the  opiate  drug  addict  will  be- 
come universally  known.  Without  familiarity  with  them 
and  understanding  of  them,  and  comprehension  and  ap- 
preciation of  their  disease,  we  shall  never  make  real  prog- 
ress in  the  solution  of  the  narcotic  drug  problem.     Prom 


10    THE  NARCOTIC  DRUG  PROBLEM 

the  present  day  trend  of  articles  and  stories  in  the  news- 
papers and  lay  and  medical  magazines  it  cannot  be  doubted 
that  the  time  is  not  far  distant  when  in  the  lay  press  will 
appear,  in  plain,  sober,  unvarnished  truth,  the  true  story 
of  the  experiences  and  struggles  of  the  opiate  drug  addict. 
I  have  marked  a  rapidly  growing  appreciation  of  facts 
and  a  steadily  increasing  activity  in  the  investigation  of 
conditions.  This  is  sooner  or  later  bound  to  be  followed 
by  intelligent  public  and  scientific  demand  for  competent 
and  common-sense  explanation  and  solution. 


CHAPTEE  II 

FUlTDAMENTAIi    CONSIDERATION'S 

My  earliest  efforts  in  the  handling  of  narcotic  addicts 
were  institutional.  They  were  along  the  lines  of  forcible 
control,  based  upon  the  theory  that  I  could  expect  no  help 
nor  co-operation  from  my  patients. 

While  this  theory  is  undoubtedly  true  as  applied  to 
many  of  those  who  have  developed  opiate  addiction,  it  is 
true  of  them  as  individuals  whose  personal  characteristics 
are  such  that  they  require  forcible  control  for  the  accom- 
plishment of  desirable  ends  in  general.  It  is  not  true  of 
them  simply  because  of  narcotic  addiction.  It  is  equally 
true  of  these  same  people  afflicted  with  other  diseases. 
Their  successful  handling  for  tuberculosis,  venereal  disease, 
cardiac  conditions,  or  anything  else  requires  for  its  suc- 
cessful issue  constant  overnight  and  what  practically 
amounts  to  custodial  care.  I  shall  refer  to  them  later. 
XV  They  are  fundamentally  custodial  or  correctional  cases 
and  success  in  their  handling  will  never  be  accomplished  in 
any  other  way,  whether  they  are  being  treated  for  narcotic 
addiction  or  for  anything  else,  mental,  moral  or  physical. 

What  appears  in  this  chapter  does  not  solve  the  prob- 
lem of  the  handling  of  the  narcotic  addict  of  this  type. 
There  are  many  factors  and  elements  in  their  mental  and 
physical  make-up  other  than  drug  addiction  which  should 
be  considered,  and  these  factors  and  elements  lie  at  the 
bottom  of  their  irresponsibility  and  the  real  difficulty  of 
their  handling. 

Experience  and  the  analysis  of  unsuccessful  effort  and 

results  showed  that,  however  necessary  forcible  control 

might  be  in  the  handling  of  some  narcotic  addicts,  it  was 

11 


y 


12  THE  NARCOTIC  DRUG  PROBLEM 

not  successful  nor  suflScient  nor  even  the  most  important 
factor  in  the  treatment  of  most  cases  of  addiction-disease. 

I  soon  came  to  see  that  I  had  an  erroneous  conception 
of  my  medical  and  clinical  problems  and  an  unjust  atti- 
tude towards  many  if  not  most  of  my  addiction  patients. 
Studying  them  —  not  as  drug  addicts,  but  as  individual 
human  beings  —  I  found  them  in  their  personal,  mental, 
moral  and  other  characteristics,  as  various  as  people  suf- 
fering from  any  other  disease  condition.  There  were 
no  narcotic  laws  at  that  time  and  opiates  were  easily  and 
cheaply  obtainable.  Very  many,  perhaps  most  of  those 
who  came  to  my  wards  were  not  forced  in  either  by  fear 
of  the  law  or  by  scarcity  of  opiate  supply.  They  did  not 
have  to  come  for  treatment,  but  voluntarily  presented 
themselves  in  the  hope  of  cure.  Something  was  wrong 
with  my  theories. 

In  seeking  for  solution  I  began  to  realize  that  the  nar- 
cotic addict  of  average  individual  characteristics  obtained 
no  enjoyment  from  the  use  of  his  opiate,  and  that  he  co- 
operated as  a  rule  to  the  extent  of  his  ability  and  endur- 
ance in  efforts  to  relieve  him  of  his  condition,  so  long  as 
he  had  any  hope  of  possible  ultimate  success.  I  learned, 
trained  and  experienced  physician  though  I  was,  that  I 
was  far  more  ignorant  of  the  clinical  manifestations  and 
physical  reactions  of  narcotic  drug  addiction  than  many 
of  the  patients  I  was  trying  to  treat.  It  was  soon  evi- 
dent to  me,  moreover,  that  the  man  who  recognized  my 
ignorance  above  all  others  was  my  patient.  I  came  to  see 
that  what  I  had  interpreted  as  lack  of  co-operation  was 
largely  due ;  first  to  his  memory  of  previous  experience, 
second  to  recognition  of  my  ignorance,  and  third  to  his 
anticipation  of  useless  and  harmful  suffering  which  he 
expected  from  my  care  and  treatment  of  his  case. 

Looking  back  over  that  period,  I  am  free  to  confess 
that  my  efforts,  though  honestly  made,  amply  realized 
his  expectations. 


FUNDAMENTAL  CONSIDERATIONS  13 

I  began  to  see  that  I  knew  nothing  of  this  disease  or 
how  to  treat  it  as  a  problem  of  clinical  disease.  I  saw 
that  addict  after  addict  sneezed  and  trembled,  jerked  and 
sweated,  vomited  and  purged,  became  pallid  and  collapsed, 
that  his  heart  and  circulation  were  profoundly  and  alarm- 
ingly disturbed,  that  he  had  the  unquestionable  facies  or 
expression  of  intense  physical  suffering,  and  the  many 
constant  and  obvious  signs  which  attend  physical  need 
for  opiate  drug.  I  could  not  escape  the  conclusion  that 
here  were  tangible,  material,  incontrovertible  physical  facts 
for  which  I  had  no  physical  explanation.  It  seemed  un- 
reasonable to  be  satisfied  with  any  explanation  of  them 
that  did  not  have  a  physical  basis ;  and  it  seemed  a  logical 
conclusion  that  the  establishment  of  a  basis  of  physical 
disease  mechanism  could  offer  the  only  hope  of  remedy.  I 
therefore  ignored  for  the  time  being  my  past  teachings  and 
ideas  of  the  drug  addict,  and  I  looked  to  the  patient  him- 
self, questioning  him  as  to  his  experiences  and  studying 
the  symptomatology  and  physical  phenomena  he  presented. 
In  short,  I  adopted  the  attitude  which  must  be  widely 
adopted  before  the  medical  problem  of  the  clinical  hand- 
ling of  drug  addiction  will  be  solved  —  in  my  attitude 
towards  these  cases  I  became  the  clinical  student  and 
practitioner  of  internal  medicine,  treating  my  patient  to 
the  best  of  my  ability  as  I  would  a  sufferer  from  any  other 
disease,  and  studying  his  case. 

Struck  by  clinical  facts  which  did  not  accord  with  past 
teaching,  I  tried  to  seek  out  from  my  personal  study  and 
observation  of  the  individual  case  data  upon  which  to 
form  theories  which  would  accord  with  clinical  facts  and 
with  verified  histories  and,  if  possible,  give  a  basis  of  help 
to  these  unfortunates. 

Gradually  since  then  I  have  gotten  together,  from  my 
own  work  and  that  of  others,  and  with  some  success  at- 
tempted to  interpret  and  explain  and  apply,  what  seemed 
to  me  facts  about  opiate   addiction.     To  my  mind  and 


14  THE  NARCOTIC  DRUG  PROBLEM 

in  my  experience  these  facts  offer  a  beacon-light  of  hope 
and  assure  ultimate  rescue  to  a  very  large  proportion  if 
not  most  of  those  suffering  from  narcotic  drug  addiction- 
disease. 

It  is  well  to  state  here  that  of  late  some  of  these  facts 
have  secured  recognition  in  medical  and  lay  authoritative 
announcement  and  literature.  The  Preliminary  Report  of 
a  special  investigating  committee  of  the  'New  York  State 
Legislature  is  quoted  from  elsewhere  in  this  book,  and  the 
report  in  June,  1919,  of  a  special  committee  appointed  by 
the  Secretary  of  the  Treasury  speaks  of,  "  the  more  or 
less  general  acceptance  of  the  old  theory  that  drug  addic- 
tion is  a  vice  or  depraved  taste,  and  not  a  disease,  as  held 
by  modern  investigators," 

It  is  on  account  of  "  the  more  or  less  general  acceptance 
of  the  old  theory  "  that  it  is  necessary  in  this  place  to 
discuss  some  of  the  tenets  of  that  theory  for  the  benefit 
of  those  whose  interests  or  emergencies  have  not  led  them 
to  investigation  of  and  familiarity  with  the  scientific  and 
other  writings  on  this  subject  of  recent  years. 

It  has  been  demonstrated  to  be  a  fact  that  description 
of  narcotic  drug  addiction  as  "  habit,"  "  vice,"  "  morbid 
appetite,"  etc.,  absolutely  fails  to  give  any  competent  con- 
ception of  its  true  characteristics,  and  clinical  and  physical 
phenomena.  A  large  majority  of  opiate  users  are  gravely 
wronged  in  a  wide-spread  opinion  still  prevalent.  This 
opinion,  as  previously  outlined,  is  that  chronic  opiate  ad- 
diction is  a  morbid  habit ;  a  perverted  appetite ;  a  vice ;  that 
only  he  who  is  mentally  or  morally  defective  will  allow 
it  to  get  a  hold  upon  him;  and  that  its  main  and  char- 
acterizing manifestations  are  those  of  mental,  physical  and 
moral  degeneration.  Opiate  addicts  are  supposed  to  have 
irrevocably  lost  their  self-respect,  their  moral  natures  and 
their  physical  stamina.  They  are  still  painted  by  many, 
as  inevitable  liars,  full  of  deceit,  and  abscjutely  untrust- 
worthy —  people  who  are  supposed  to  use  'a  dream  and 


FUNDAMENTAL  CONSIDERATIONS         15 

deliglit  producing  drug  for  the  sensuous  enjoyment  it  gives 
them,  and  who  do  not  want  to  discontinue  its  use.  They 
are  thought  of  as  physical,  mental  and  moral  cowards  who, 
after  realizing  their  deplorable  condition,  refuse  to  exert 
"  will-power  "  enough  to  stop  the  administration  of  opiates. 

With  these  views  I  did  my  early  work  on  this  condition. 
On  these  hypotheses,  trying  to  follow  current  available 
literature  and  teaching,  I  treated  my  patients  for  a  con- 
siderable time  with  results  which  superficially  interpreted 
seemed  to  corroborate  both  literature  and  teaching.  Many 
of  them  managed  to  get  their  drugs  even  while  in  the  in- 
stitution, and  practically  all  of  them  left  uncured  with 
but  an  exceedingly  small  number  of  possible  exceptions. 

From  my  patients  themselves,  and  from  watching  and 
studying  them,  I  later  learned  the  truth,  which  has  since 
been  continually  strengthened  —  that  the  so-called  "  dis- 
comforts "  we  think  of  them  as  suffering  upon  withdrawal 
of  their  drug,  are  actually  unbearable  suffering,  accom- 
panied by  physical  manifestations  sufficient  to  prove  this 
to  be  so.  I  also  learned  that  the  supposed  delightful  sen- 
sations which  have  formed  the  background  of  most  pic- 
tures painted  of  them,  had  in  many,  if  not  in  most  of  the 
cases  with  which  I  came  in  contact,  never  been  experienced. 
If  they  had  ever  existed  they  had  long  ago  been  lost  and 
all  that  remained  in  opiate  effect  was  support  and  balance 
to  organic  processes  necessary  to  the  continuance  of  life 
and  economic  activity.  As  I  have  written,  these  sensa- 
tions seem  to  be,  "  part  of  the  minor  toxic  action  of  the 
opiate  against  which  the  addict  is  nearly  or  completely 
immune  and  to  the  securing  of  which  very  many  and  prob- 
ably a  majority  of  the  innocent  or  accidental  addicts  have 
never  carried  their  dosage."  In  plain  English  the  sufferer 
from  opiate  addiction  has,  in  many  if  not  a  majority  of 
cases,  never  experienced  any  enjoyment  as  a  result  of  the 
drug  and  has  endured  indescribable  agony  in  its  non- 
supply. 


16  THE  NARCOTIC  DRUG  PROBLEM 

I  do  not  want  to  be  understood  as  claiming  that  opiates 
will  not  produce  pleasant  sensations,  nor  that  they  are 
never  used  to  the  end  of  experiencing  these  sensations. 
There  is  a  class  of  the  inherently  or  otherwise  defective 
or  degenerate,  who  first  indulge  in  opium  or  its  products 
from  a  morbid  desire  for  sensuous  pleasures,  just  as  they 
would  and  do  indulge  in  any  form  of  perversion  or  gratify 
any  idle  curiosity.  They  are  mentally  incapable  of  self- 
restraint,  indulging  jaded  appetite  with  new  stimuli. 
They  yield  themselves  to  any  and  all  forms  of  self-indul- 
gence and  gratification  of  appetite.  There  comes  a  time 
when  for  them  opiates,  from  increasing  tolerance  and  de- 
pendence lose  power  to  give  pleasurable  sensations  and  be- 
come simply  a  part  of  their  daily  sustenance,  exacting 
physical  agony  as  a  result  of  their  non-administration. 
When  this  occurs  they  make  no  effort  to  control  amount 
or  method  or  use ;  and  overdosage  together  with  conditions 
incidental  to  and  attendant  upon  their  mode  of  life  soon 
relieves  society  of  the  menace  of  their  membership.  As 
a  class  they  have  been  regarded  as  incurable  and  hopeless 
—  socially,  economically  and  personally  unworthy  of  sal- 
vage. To  whatever  extent  this  may  be  true,  however,  it 
is  not  true  simply  because  they  happen  to  have  acquired 
opiate  addiction,  but  because  they  are  fundamentally  what 
they  are,  diseased,  degenerate  and  defective. 

The  opiate  element  is  as  incidental  to  their  fundamental 
condition  as  are  the  venereal  and  other  diseases  from  which 
many  if  not  most  of  them  suffer.  Observations  and  con- 
clusions upon  addicts  from  this  type  of  humanity  have  been 
given  great  prominence  in  the  public  press  and  elsewhere 
and  have  had  an  unwarranted  influence  in  the  status  of 
opiate  addiction  and  the  conception  of  and  attitude  towards 
the  addiction  sufferer.  Because  addicts  of  this  class  began 
to  use  opium  or  its  derivatives  and  products  to  secure  sensu- 
ous gratification  is  no  reason  for  stigmatizing  the  mass  of 
those  afflicted  with  addiction-disease  as  people  of  perverted 


FUNDAMENTAL  CONSIDERATIONS  17 

appetites.  No  one  should  study  addiction  in  them  unless 
lie  is  possessed  of  sufficient  ability  in  clinical  observation 
to  separate  physical  signs  of  opiate  addiction  from  the 
manifestations  of  defective  mentality  —  and  unless  he  has 
enough  insight  and  breadth  of  vision  to  see  behind  end- 
results,  primary  causative  factors;  and  unless  he  has 
enough  common-sense  to  refrain  from  applying  to  the 
worthy  many  the  observations  he  has  made  upon  the  un- 
worthy few. 

It  is  only  fair  to  state  in  passing,  however,  that  from  my 
experiences  as  Visiting  Physician  in  the  wards  of  the 
Workhouse  Hospital,  New  York  Department  of  Correc- 
tion, I  am  convinced  that  we  all  too  often  casually  include 
in  the  above  generally  considered  derelict  class  of  society, 
many  who  under  intelligent  and  humane  handling  could 
be  restored  to  or  converted  into  useful  citizens. 

There  are  some  above  this  class,  of  the  type  of  spoiled 
and  idle  youth,  who  indulge  first  in  opiates  in  a  spirit  of 
bravado  or  curiosity.  The  tremendous  increase  in  addic- 
tion since  its  spectacular  incidental  and  morbid  aspects 
became  so  widely  published  is  largely  contributed  to  from 
this  class. 

There  are  some  who  first  used  opiates  to  temporarily 
boost  them  over  an  emergency,  post-alcoholic  excesses, 
severe  mental  strain,  etc. 

The  majority  of  narcotic  addicts,  however,  and  especially 
those  developing  previous  to  the  activities  of  the  past  few 
years,  present  a  very  different  history,  Mentally  and 
morally  they  are  of  the  same  average  equipment  as  other 
people.  They  form  a  class  which  might  be  called  "  acci- 
dental or  innocent  "  addiction-disease  sufferers.  They  had 
no  voice  nor  conscious  part  in  the  early  administration  of 
opiate,  realizing  no  desire  or  need  for  it  by  name,  but 
only  wishing  for  the  unknown  medicine  which  relieved 
their  sufferings.  Very  many  addiction  patients  have  re- 
ceived their  first  knowledge  of  opiate  administration  in 


18    THE  NARCOTIC  DRUG  PROBLEM 

the  withdrawal  symptoms  which  followed  the  attempted 
discontinuance  of  its  use.  There  is  in  these  sufferers  no 
element  of  lack  of  will-power;  no  trace  of  desire  to  in- 
dulge appetite  or  to  pander  to  sensuous  gratification.  In 
some,  before  their  condition  was  recognized,  their  tolerance 
for  or  dependence  upon  opiate  had  proceeded  to  a  point 
where  their  bodies'  demand  for  morphine  was  imperative 
and  their  withdrawal  suffering  unendurable.  In  others, 
before  body  need  was  completely  established  —  with  their 
stamina  and  nervous  resistance  below  par  from  sickness 
and  suffering  —  they  have  been  unable  to  forego  opiate's 
supportive  and  sedative  and  pain-relieving  action,  or  to 
endure  the  nervous  and  other  symptoms  attendant  upon  its 
withdrawal  after  even  a  brief  period  of  administration. 

As  to  what  the  addict  is ;  —  the  tendency  and  effect 
of  legislative,  administrative,  police  and  penological  ac- 
tivities in  general  have  been  to  place  the  sufferer  from 
addiction-disease  in  the  position  of  the  criminal  and 
vicious.  The  tendency  of  the  psychologist  and  psychiatrist 
is  to  analyze  him  from  the  viewpoint  of  mental  weakness, 
defect  or  degeneration,  and  to  so  classify  and  regard  him. 
The  average  practitioner  of  internal  medicine,  and  even 
the  recognized  leaders  and  authorities  in  this  field  of 
medical  science  will  tell  you  that  narcotic  drug  addiction 
is  a  condition  to  which  they  have  given  but  little  attention 
and  have  no  clean-cut  ideas  of  its  physical  disease  problems. 
The  addict  himself,  whose  testimony  has  been  all  too  little 
consulted  or  sought,  will  tell  you  that  he  is  sick  with  some 
kind  of  a  physical  condition  which  causes  suffering  and 
incapacity  whenever  a  sufficient  amount  of  narcotic  is  not 
administered. 

In  the  above  attitudes  and  statements  the  administrative, 
police  and  penological  authorities  are  right  in  some 
cases ;  —  the  psychologists  and  psychiatrists  have  good 
basis  for  their  opinions  in  some  cases ;  —  the  addict  has 


FUNDAMENTAL  CONSIDERATIONS         19 

physical  grounds  for  his  statement  in  all  cases  ■ — ■  he  is 
always  sick,  sick  with  addiction-disease. 

In  my  experience  with  and  study  of  narcotic  drug  addic- 
tion and  the  narcotic  drug  addict,  an  experience  touching 
practically  every  phase  of  the  narcotic  situation  and  giving 
me  opportunity  to  observe  the  condition  in  practically 
every  type  of  individual,  the  one  constant  and  more  and 
more  strikingly  emphasized  observation  has  been  constant 
physical  symptomatology  and  the  manifestations  of  pain 
and  suffering  and  of  fear.  I  have  in  my  possession  his- 
tories of  addicts  taken  from  all  walks  of  life  and  from 
all  classes  and  conditions  of  men.  Some  of  my  histories 
are  of  patients  who  were  primarily  defective,  degenerate, 
weak  or  vicious.  Some  of  my  histories  are  of  people  of 
high  mentality;  of  high  ethical  and  moral  standards;  of 
high  economic  efficiency  and  social  standing.  These  his- 
tories, stripped  of  names  and  possibilities  of  personal  recog- 
nition, would  form  a  very  instructive  collection  of  material 
for  the  man,  physician,  psychologist,  sociologist,  legislator 
or  administrator  who  wishes  to  study  the  addict  as  he 
really  is  and  to  get  some  conception  of  the  diversity  of  the 
problems  which  he  presents. 

I^eglect  of  this  study  and  absence  of  this  conception  is 
the  chief  cause  of  past  failure.  We  have  tended  to  re- 
gard and  handle  and  treat  and  legislate  concerning  narcotic 
addicts  simply  as  narcotic  addicts,  instead  of  appreciating 
that  different  individuals  and  different  types  and  classes 
of  people  who  may  suffer  from  addiction-disease  present 
entirely  different  problems,  and  require  entirely  different 
handling. 

If  we  are  going  to  consider  all  narcotic  addicts  as  in  one 
class  we  can  with  justice  only  consider  those  characteristics 
which  are  common  to  all  members  of  that  class.  There  is 
just  one  fact  and  characteristic  that  stands  out  as  of  strik- 
ing and  paramount  importance  in  every  one  of  my  histories 


20  THE  NARCOTIC  DRUG  PROBLEM 

—  it  is  the  fact  of  physical  suffering  upon  complete  with- 
drawal of  opiate  drug,  or  a  supply  of  that  drug  which  does 
not  meet  the  requirements  of  the  physical  body-need. 
Whatever  or  whoever  the  narcotic  addict  was  before  his 
use  of  opiate  drugs  —  whatever  had  been  the  character 
and  circumstances  of  the  initial  administration  of  narcotic 
drug  —  after  a  time,  as  I  have  repeatedly  written  else- 
where, after  addiction-disease  has  once  developed,  the  his- 
tory of  every  opiate  addict  is  that  of  suffering  and  of 
struggle.  After  addiction-disease  is  once  developed  the 
addict  loses  whatever  euphoric  sensation  he  may  possibly 
have  experienced,  and  all  that  narcotic  administration 
spells  for  him  is  relief  from  suffering.  Without  the  drug 
of  his  addiction  he  endures  intense  physical  suffering  and 
misery.  Without  the  drug  of  his  addiction  he  cannot  pur- 
sue a  social,  economic,  or  physically  endurable  existence. 
He  may  have  been  primarily  defective,  degenerate,  de- 
praved or  vicious ;  his  primary  administration  of  the  drug 
may  have  been  deliberate  indulgence,  disreputable  associa- 
tions, idle  curiosity,  any  combination  of  conditions  which 
may  be  stated ;  —  he  may  have  been  an  upright,  honest  and 
intelligent,  hard-working,  self-supporting,  worthy  and  nor- 
mal citizen  in  whom  the  primary  administration  of  opiate 
drug  was  a  result  of  unwise,  ignorant  or  unavoidable  medi- 
cation ;  —  he  may  have  been  an  ignorant  purchaser  of 
advertised  patent  medicines  containing  addiction-forming 
drugs.  Whatever  his  original  status,  mental,  moral,  physi- 
cal or  ethical,  and  whatever  the  circumstances  of  his 
primary  indulgence;  once  addiction-disease  has  developed 
in  his  body  the  vital  fact  of  his  history  is  the  same  —  sub- 
sequent use  of  opiate  drug  means  not  pleasure,  not  vice, 
not  appetite,  not  habit  —  it  means  relief  of  physical  suf- 
fering and  the  control  of  physical  symptoms. 

My  present  definition  of  narcotic  drug  addiction  is  as 
follows;  a  definite  physical  disease  condition,  presenting 
constant  and  definite  physical  symptoms  and  signs,  prog- 


FUNDAMENTAL  CONSIDERATIONS         21 

ressing  througli  clean-cut  clinical  stages  of  development, 
explainable  by  a  mechanism  of  body  protection  against 
the  action  of  narcotic  toxins,  accompanied  if  nnskillfully 
managed  by  inhibition  of  function,  autotoxicosis  and  auto- 
toxemia,  its  victims  displaying  in  some  cases  deteriora- 
tion and  psychoses  which  are  not  intrinsic  to  the  disease, 
but  are  the  result  of  toxemia,  and  toxicosis,  malnutrition, 
anxiety,  fear  and  suffering. 

To  express  this  somewhat  differently  —  a  narcotic  drug 
addict  is  an  individual  in  whose  body  the  continued  ad- 
ministration of  opiate  drugs  has  established  a  physical  re- 
action, or  condition,  or  mechanism,  or  process  which  mani- 
fests itself  in  the  production  of  definite  and  constant  symp- 
toms and  signs  and  peculiar  and  characteristic  phenomena, 
appearing  inevitably  upon  the  deprivation  or  material  les- 
sening in  amount  of  the  narcotic  drug,  and  capable  of 
immediate  and  complete  control  only  by  further  adminis- 
tration of  the  drug  of  the  patient's  addiction. 

In  plain  English,  the  sufferer  from  narcotic  drug  addic- 
tion-disease is  one  who  experiences  the  symptoms  and 
signs  referred  to  above  and  which  will  be  discussed  later, 
as  a  result  of  lack  of  supply  or  physically  insufficient 
supply  of  opiate  drug.  I  know  of  no  definition  along  any 
other  lines  which  will  include  all  who  suffer  from  narcotic 
drug  addiction.  This  symptomatology,  and  the  mechan- 
ism or  process  which  produces  it,  are  the  only  common  and 
characteristic  attributes  and  possession  of  all  opiate  addicts. 

How  these  are  developed  and  how  they  may  be  controlled 
and  arrested  is  the  demand  which  the  sufferer  from  narcotic 
drug  addiction,  and  society  as  a  whole,  are  making.  Un- 
til a  competent  and  acceptable  answer  to  this  demand  is  in 
the  general  possession  of  those  handling  narcotic  addic- 
tion, all  other  discussions  will  remain  inconclusive,  and 
all  other  considerations  incidental,  for  purposes  of  definite 
and  final  solution.  This  is  the  medical  problem  of  narcotio 
drug  addiction,  and  until  those  who  handle  narcotic  ad- 


22    THE  NARCOTIC  DRUG  PROBLEM 

diets,  and  those  who  eontrol  the  handling  of  narcotic  ad- 
dicts, have  recognized  it,  are  familiar  with  it,  and  can  to 
some  working  measure  explain  and  control  its  sufferings, 
physical  phenomena  and  symptoms  and  signs,  they  are  un- 
prepared to  assist  intelligently  and  competently  in  the 
solution  of  a  prohlem  which  now  as  never  before  menaces 
the  welfare  of  society. 


CHAPTEE,  III 

THE    ITATUEE    OF    NAECOTIC    DEUG   ADDICTION-DISEASE 

It  is  a  pertinent  question  to  ask,  "  What  type  or  class 
of  individuals  become  narcotic  addicts  ?  "  The  only  cor- 
rect answer  unquestionably  is,  any  type  or  class  or  in- 
dividual to  whom  opiates  are  given  for  a  suflSciently  long 
time.  It  has  yet  to  be  demonstrated  that  there  is  any 
warm-blooded  animal,  which  following  sufficiently  pro- 
longed and  constant  administration  of  opiate  drug,  is  im- 
mune to  the  development  of  the  symptomatology  and  con- 
stant physical  phenomena  of  addiction-disease. 

Color,  nationality,  social  or  economic  position,  age, 
mental  and  moral  attributes  of  whatever  sort  are  no  bar 
to  the  development  of  the  condition.  These  may  influence, 
of  course,  the  conduct  and  incidental  manifestations  of  the 
individual  addicted,  just  as  they  do  in  any  other  condi- 
tion. The  addicted  judge,  or  the  addicted  physician,  or 
the  addicted  clergyman,  or  the  addicted  man  of  business 
or  other  affairs,  or  the  addicted  clerk  or  industrial  worker 
reacts  differently  to  the  sufferings  and  trials  of  narcotid 
drug  addiction  than  does  the  addict  of  the  underworld,  or 
the  heroin  "  sniffer "  of  idle  and  curious  adolescence,  or 
the  addicted  defective,  degenerate,  or  criminal.  Also  he 
reacts  differently  to  everything  else.  What  is  true  of  one 
man  who  has  opiate  addiction  may  be  absolutely  false  of 
another.  One  narcotic  addict  is  honest,  competent,  truth- 
ful and  intelligent.  Another  is  dishonest,  incompetent, 
untruthful  and  incapable  of  appreciation  or  self-control. 
Neither  the  one  set  of  attributes,  nor  the  other,  is  peculiar 

to  narcotic  addicts.     They  are  simply  personal  attributes 

23 


24.  THE  NARCOTIC  DRUG  PROBLEM 

possessed  by  different  men  and  types  of  men  who  may  or 
may  not  be  narcotic  addicts.  If  the  addict  of  a  higher 
type  displays  at  times  attributes  not  typical  of  his  pre- 
addicted  days,  and  seems  to  show  a  lowering  of  his  mental 
and  ethical  tone,  it  is  well  to  estimate  in  his  case  the  in- 
fluences of  past  worry,  fear,  suffering,  strain  and  struggle, 
the  attitude  of  society,  medical  and  lay,  towards  him,  and 
the  manner  in  which  he  has  been  handled,  before  blaming 
it  all  upon  the  mere  presence  and  effects  of  narcotic  drug 
addiction,  or  of  narcotic  drug.  If  such  changes  were  in- 
herent in  the  action  of  continued  narcotic  drug  medication, 
they  would  be  found  in  all  addicts,  whereas  the  fact  is  that 
they  most  decidedly  are  not. 

As  to  age  in  addicts  there  is  no  limit.  I  have  seen  an 
infant  newly-born  of  an  addicted  mother,  displaying  the 
characteristic  physical  symptoms,  signs  and  phenomena  of 
body-need  for  opiate  a  few  hours  after  birth.  This  case 
is  discussed  more  in  detail  in  the  transcribed  testimony  of 
the  New  York  State  Legislative  Investigation  hearings, 
(Whitney  Committee)  pages  1524  to  1529,  at  which  I  re- 
ported it.  The  infant  undoubtedly  developed  addiction- 
disease  prenatally,  reacting  in  its  unborn  body  against  the 
presence  of  opiates,  supplied  through  its  mother's  blood, 
exactly,  as  is  now  demonstrated  through  experimental  labo- 
ratory animals  and  by  clinical  study  upon  adults,  this 
disease  is  always  developed  —  through  physical '  and  con- 
stant reaction  of  the  body  to  the  continued  presence  of 
opiates,  however  supplied.  There  have  been  many  such 
cases,  some  of  which  are  matters  of  medical  record.  This 
condition  of  prenatal  development  of  addiction-disease 
exists  beyond  dispute  and  certainly  cannot  be  explained 
upon  grounds  of  conscious  appetite  or  deliberate  self- 
indulgence.  I  am  told  that  there  are  or  until  very  recently 
have  been  old  soldiers,  veterans  of  the  Civil  War,  whose 
addiction  dated  from  medication  for  wounds  received  dur- 
ing that  struggle.     The  late  Doctor  T.  D.  Crothers  told 


NARCOTIC  DRUG  ADDICTION-DISEASE     25 

me  once  that  opiate  addiction  in  this  country  received  its 
first  wide  dissemination  in  that  way.  This  points  to  the 
serious  consideration  of  what  may  be  an  urgent  and  im- 
portant medical  prohlem  of  modem  warfare. 

This  brings  ns  up  to  the  origin  of  addiction.  There  is 
only  one  actual  origin  of  addiction,  and  that  is  the  con- 
tinued administration  of  an  addiction-developing  drug  suf- 
ficiently long  to  develop  the  physical  manifestations  symp- 
tomatology, and  phenomena  and  body  need  for  that  drug. 
This  statement  is  the  only  one  which  can  be  made  as  gen- 
erally inclusive.  I  have  many  records  and  histories,  much 
correspondence,  and  other  data,  collected  from  addicts, 
relatives,  friends  and  associates  of  addicts,  physicians, 
official  conferences  and  workers  in  the  various  fields  of 
narcotic  endeavor.  My  material  covers  an  active  interest 
of  many  years  duration,  and  an  experience  which  has  dealt 
with  various  types  and  classes  of  patients  under  various 
conditions.  I  have  held  different  beliefs  at  different  times, 
influenced  by  the  demands  of  my  immediate  position,  and 
by  my  best  interpretation  of  my  own  experience,  by  the 
conditions  under  which  I  happened  to  be  working  and  by 
the  class  of  people  coming  to  my  attention  under  the  con- 
ditions of  my  work.  At  one  time  I  believed  that  all  addicts 
were  defective,  irresponsible,  degenerated,  unreliable  and 
liars,  made  addicts  by  curiosity,  environment  and  morbid 
appetite.  At  one  time  I  believed  that  the  narcotic  addict 
did  not  physically  need  narcotic  drug  under  any  circum- 
stances, and  that  he  could  get  along  without  it  if  he  only 
had  the  will  and  the  desire  to  do  so.  I  proceeded  on  that 
theory  for  a  while  in  the  handling  of  my  cases,  and  have 
to  thank  the,  illicit  supply  which  is  present  in  all  institu- 
tions that  my  mortality  was  no  higher,  for  it  is 
agreed  and  on  record  by  many  competent  authorities  that 
forcible  deprivation  of  opiate  drug  may  at  times  cause 
death. 

These  are  examples  of  a  few  of  the  various  beliefs  and 


26     THE  NARCOTIC  DRUG  PROBLEM 

ideas  I  have  held  at  various  times,  and  upon  which  I  used 
to  generalize^  as  is  the  habit  and  tendency  of  those  who 
as  yet  lack  experience  or  breadth  of  experience.  I  have  in 
time  found  many  of  my  beliefs  wholly  or  partly  erroneous, 
or  to  apply  only  to  selected  groups  of  cases  or  to  incidental 
phases  and  aspects  of  the  main  problem.  They  all  have 
their  bearings  on  the  general  situation,  and  may  be  of 
primary  importance  in  the  immediate  handling  and  control 
of  certain  phases  of  it.  I  have  come  now  to  keep  my 
general  statements  to  the  solid  rock  of  basic  disease  and 
draw  on  my  past  experience  for  the  measure  and  estimation 
of  associated  problems  and  complications  as  they  arise. 

The  actual  origin  of  addiction  is  the  administration  of 
opiate  drugs  continuously  over  a  sufficient  length  of  time. 
The  incidental  details  in  their  early  administration  to 
those  who  become  addicted  vary  widely.  In  the  origin  of 
some  proportion  of  addicts,  we  of  the  medical  profession 
must  sooner  or  later  come  to  recognize  and  assume  our  part, 
unconscious  and  innocent,  but  none  the  less  beyond  ques- 
tion. What  this  proportion  is  is  variously  estimated  by 
various  authorities  and  statisticians  and  investigators.  It 
is  now  beyond  dispute  that  many  cases  of  addiction-disease 
had  their  origin  in  medication  during  illness,  the  condi- 
tion developing  unsuspected  by  either  physician  or  by 
patient  until  its  physical  manifestations  had  passed  the 
bounds  of  control. 

The  old  fallacy  that  an  opiate  might  be  administered 
safely  to  a  sufferer  so  long  as  the  patient  did  not  know 
what  was  being  given  him  is  completely  disproven  by  the 
evidence  of  addicted  infants,  and  by  the  excellent  and  ex- 
haustive laboratory  experiments  upon  addicted  animals  by 
such  men  as  Giofreddi,  Hirschlaff  and  more  recently 
Valenti  of  Italy  whose  work,  published  in  1914,  should 
have  widest  recognition.  This  fallacy  has  been  responsible 
for  many  a  case  of  addiction.  Very  many  opiate  addicts 
have  passed  into  the  stage  of  fully  established  addiction- 


NARCOTIC  DRUG  ADDICTION-DISEASE     27 

disease  before  they  were  aware  that  they  had  ever  taken 
an  opiate. 

Clinical  familiarity  with  the  symptoms  and  signs  of 
beginning  and  developing  addiction  should  be  the  posses- 
sion of  every  physician  and  snrgeon.  It  would  save  from 
the  physicial  sufferings,  and  mental  tortures  and  fears 
of  narcotic  addiction  many  human  beings.  It  has  been  my 
experience  when  called  in  as  a  medical  consultant  upon 
medical  and  surgical  cases  whose  progress  towards  recov- 
ery seems  unaccountably  tedious  and  unsatisfactory,  to 
detect  as  the  basis  for  the  lack  of  function  and  recuperative 
power,  unsuspected  developing  opiate  addiction  in  time  to 
prevent  its  further  progress.  Unwisely  prolonged  opiate 
medication  makes  more  opiate  addicts  than  we  have  real- 
ized. 

The  addict  in  whom  it  is  most  profitable  to  study  addic- 
tion origin  and  development  and  handling,  if  we  are  to  get 
a  clean-cut  picture  of  addiction-disease,  is  the  individual 
who  is  primarily  normal,  mentally,  morally  and  physically, 
whose  addiction  condition  is  a  result  of  ignorant,  mis- 
guided or  unavoidable  medication,  either  professionally  or 
self-^administered.  Their  number  is  far  greater  than  is 
yet  generally  appreciated.  Many  if  not  most  of  them  are 
unsuspected  and  unknown  and  they  include  eminent  peo- 
ple in  all  walks  of  life.  They  are  social,  and  economic 
assets  whose  interests  and  welfare  we  cannot  ignore  when 
we  are  considering  the  disposition  and  handling  of  the 
narcotic  addict. 

Many  of  them  have  gone  from  one  institution  to  another, 
and  have  attempted,  in  desperate  effort  to  be  cured,  each 
newly-discovered  and  announced  specific  or  theory  of  treat- 
ment. They  have  never  derived  any  pleasure  from  nar- 
cotic use.  For  them  the  narcotic  drug  has  been  only  neces- 
sary medication  to  relieve  physical  suffering  and  to  main- 
tain economic  existence  and  the  support  of  themselves  and 
their  families.     They  should  be  classed  as  innocent   or 


28    THE  NARCOTIC  DRUG  PROBLEM 

accidental  addicts  —  normal  and  worthy  sick  people. 
They  earnestly  desire  treatment  and  help,  and  once  their 
addiction  process  is  completely  arrested  do  not  tend  to 
return  to  narcotic  drug  use.  Whatever  associations  they 
may  have  had  with  the  unworthy  or  unfit  of  the  so-called 
"  underworld ''  and  with  illicit  and  illegitimate  traffic  has 
been  the  result  of  desperate  necessity,  in  their  best  judg- 
ment, in  the  obtaining  of  opiate  supply  when  it  has  seemed 
to  them  to  be  otherwise  denied  them,  and  which  was  neces- 
sary to  them  for  the  relief  and  avoidance  of  suffer- 
ing and  for  the  maintaining  of  a  condition  making  pos- 
sible self-support  and  the  avoidance  of  revelation  and 
disgrace. 

The  narcotic  addict  of  this  type  presents  primarily  and 
^  fundamentally  a  purely  medical  problem.  Competent  and 
complete  arrest  of  the  physical  mechanism  of  narcotic 
drug  need  permanently  removes  him  from  the  ranks  of  the 
narcotic  drug  user.  The  problem  of  his  handling  is  one 
falling  within  the  province  of  medical  practice.  His  care 
is  purely  and  simply  a  matter  of  the  treatment  of  disease 
with  medical  intelligence  and  judgment  on  the  established 
lines  of  medical  practice  in  disease  conditions  generally. 
His  after-care  is  simply  such  management  of  convalescence 
as  is  needed  in  ordinary  medical  cases.  The  length  of 
his  convalescence  will  depend  entirely,  just  as  in  other 
diseases,  upon  the  competency  and  intelligence  of  his  medi- 
cal handling  and  upon  his  physical  condition,  reaction,  and 
recuperative  ability. 

For  such  a  man  custodial  care  and  institutional  handling 
under  conditions  of  enforced  restraint  are  undesirable  and 
harmful.  His  withdrawal  from  self-supporting  citizen- 
ship should  be  for  the  shortest  time  commensurate  with 
adequate  therapeutic  results.  He  should  be  restored  to 
normal  personal,  social,  and  economic  environment  and 
activity  at  as  early  a  time  as  possible  following  his  clinical 


NARCOTIC  DRUG  ADDICTION-DISEASE     29 

treatment  and  the  arrest  of  his  physical  mechanism  of 
addiction-disease.  Given  intelligent  clinical  handling, 
with  rational  therapeutic  treatment,  and  a  comprehensive 
meeting  of  the  indications  of  disease  in  his  case,  he  is  no 
more  a  subject  for  unusual  restraint  and  custodial  care 
than  is  a  case  of  malaria  or  pneumonia  or  other  medical 
condition.  He  is  in  most  cases  a  clinically  curable  medical 
case.  He  presents  the  true  picture  of  addiction-disease 
uncomplicated  by  the  distracting  and  confusing  incidentals 
often  met  with  in  the  types  of  cases  more  commonly  dis- 
cussed. The  development  of  addiction  in  a  case  of  this 
type  is  a  purely  physical  matter,  and  is  the  addiction  which 
should  be  considered  in  the  fundamental  comprehension 
of  basic  facts. 

Stages  of  Addiction  Development 

Every  case  of  well-developed  addiction  has  followed  in 
its  development  a  course  through  several  stages,  definitely 
marked  by  clinical  signs  and  reaction  phenomena.  I  shall 
not  exhaustively  discuss  all  of  these  stages  and  their  phe- 
nomena. The  ones  I  shall  mention  will  be  recognized  by 
most  of  those  who  have  gone  through  them  or  have  watched 
them  develop. 

1.  8tage  of  Normal  Reaction  to  Therapeutic  and  Toxic 
Doses. 

The  manifestations  of  this  state  in  morphine  adminis- 
tration for  example  are  more  fully  described  in  our  text- 
books of  materia  medica  than  I  can  take  space  for  in  this 
book,  and  are  familiar  to  all  physicians.  The  narcotic 
and  analgesic  effect  with  therapeutic  doses ;  the  euphoric 
and  inhibitory  action  of  doses  in  excess  of  the  therapeutic ; 
the  toxic  action  manifested  by  the  slowed  pulse,  slowed 
respiration,  and  generally  arrested  metabolism  and  func- 
tion are  too  familiar  to  need  elaboration. 


30     THE  NARCOTIC  DRUG  PROBLEM 

2.  Stage  of  Increased  Tolerance, 

following  continuous  and  consecutive  administration  of 
morphine  (and  the  same  is  true  of  other  opiates)  comes 
failure  to  secure  the  effect  which  followed  the  early  ad- 
ministration. Larger  doses  are  needed  for  the  relief  of 
pain  or  other  symptoms,  or  the  original  doses  give  re- 
lief for  a  shorter  time.  Toxic  manifestations  do  not 
follow  what  would  formerly  have  been  a  toxic  dose.  The 
patient  requires  what  was  formerly  a  toxic  dose  to  secure 
the  former  therapeutic  effect.  The  phenomena  of  this 
stage  are  familiar  to  every  observing  clinician  who  has  used 
or  seen  morphine  used  for  continued  therapeutic  action. 
The  patient  has  acquired  an  increased  tolerance  of  the 
drug  and  a  beginning  immunity  to  its  toxic  action.  He 
does  not,  however,  suffer  appreciable  hardship  from  drug 
deprivation.  Discontinuance  of  the  drug  causes  little  or 
none  of  the  symptoms  to  be  described  as  "  withdrawal 
signs." 

3.  Stage  of  Beginning  Addiction, 

Following  the  stage  of  increased  tolerance  comes  a  stage 
where  discontinuance  or  lack  of  administration  of  the 
narcotic  drug  gives  definite  signs  and  symptoms,  beginning 
"  withdrawal  signs,"  due  to  some  beginning  physical  body 
demand  for  the  drug  and  completely  relievable  only  by  its 
administration.  These  signs  are  identical  with  the  first 
appearing  withdrawal  signs  in  a  case  of  established  addic- 
tion but  as  yet  do  not  go  beyond  the  beginning  manifesta- 
tions of  "  withdrawal "  in  a  completely  developed  addic- 
tion. They  are  limited  to  a  peculiar  nervousness,  rest- 
lessness, weakness,  depression,  etc.  They  persist  for  a  few 
days  only  if  the  drug  is  denied  and  are  endurable. 

As  to  length  of  time  required  for  the  passage  through 
each  of  these  previous  stages  or  through  both  of  them  — 
dogmatic  statement  is  impossible.     The  time  is  apparently 


NARCOTIC  DRUG  ADDICTION-DISEASE     31 

influenced  by  a  number  of  factors.  Of  course  the  varying 
inherent  resistance  or  susceptibility  of  different  individuals 
to  any  given  disease  condition  must  be  considered  in  this 
disease.  It  varies  also  with  different  forms  of  opiates 
used  and  their  modes  of  administration.  The  probable 
physical  factors  I  am  not  yet  ready  to  discuss.  The  recent 
Report  of  the  Special  Committee  of  the  Treasury  Depart- 
ment says,  "  Any  one  repeatedly  taking  a  narcotic  drug 
over  a  period  of  30  days,  in  the  case  of  a  very  susceptible 
individual  for  10  days,  is  in  grave  danger  of  becoming  an 
addict."  Certainly  a  physician  should  look  for  the  signs 
and  symptoms  of  tolerance  and  beginning  addiction 
throughout  his  opiate  administration.  It  is  also  well  to 
exhaustively  inquire  into  possible  past  history  of  unrecog- 
nized addiction  in  any  of  its  three  general  stages.  Some 
of  those  patients  who  have  demonstrated  an  apparent  un- 
usual susceptibility  and  very  rapid  development  will  be 
found  on  careful  analysis  to  have  experienced  an  un- 
recognized or  forgotten  addiction  in  some  stage  of  develop-^ 
ment.     I  have  interesting  data  on  this  point. 

4.  Stage  of  Established  Addiction, 

In  this  stage  the  "  withdrawal  "  symptoms  and  signs  be- 
come more  evident  as  results  of  opiate  deprivation.  They 
proceed  through  the  mild  discorofort  and  nervousness  of 
the  previous  stage  to  the  definite  manifestations  and  con- 
stant unmistakable  withdrawal  phenomena  to  be  described. 
The  patient  endures  physical  suffering  and  displays  all 
the  clinical  evidence  of  it.  There  can  be  no  question  of 
will-power  in  this  stage,  nor  of  desire  for  narcotic  drug 
for  any  other  purpose  than  to  escape  physical  suffering. 
Whether  the  patient  was  primarily  an  innocent  and  un- 
conscious recipient  of  the  drug,  or  of  the  class  of  the 
vicious  and  weak,  he  is  now  fundamentally  a  sick  man, 
afflicted  with  a  physical  disease.  Whether  or  not  he  ever 
experienced  any  euphoria  or  sensuous  enjoyment,  he  now 


S2  THE  NARCOTIC  DRUG  PROBLEM 

gets  nothing  of  pleasure  from  narcotic  administration.  He 
gets,  sirrvply,  relief  from  suffering.  The  opiate  drug  has 
become  his  only  immediate  means  of  securing  and  main- 
taining a  physical  efficiency,  a  semblance  of  normality. 
ifsTo  other  drug  will  take  its  place.  He  can  take  tremendous 
doses  without  toxic  effect.  In  this  stage,  if  the  drug  is 
denied  or  withdrawn  without  competent  handling,  his 
suffering  and  incompetency  is  not,  as  in  the  previous  stage, 
a  matter  of  days  but  may  persist  for  weeks  or  months 
after  no  narcotic  has  been  administered. 

The  general  stages  of  addiction-disease  development  as 
above  rather  superficially  outlined  are  not  of  course  sharply 
marked  in  their  transitions.  They  slowly  merge  one  into 
the  next  and  taken  together  constitute  a  gradual  develop- 
ment from  normal  reaction  to  opiate  to  established  addic- 
tion-disease. 

Most  patients  are  in  or  nearing  the  stage  of  developed 
addiction  when  they  are  recognized  or  come  for  treatment. 
Developed  addiction  for  narcotic  drug  means  physical, 
bodily  need  for  that  drug;  functional  incompetency  and 
suffering  without  that  drug;  comparative  normality  and 
efficiency  only  to  be  immediately  secured  and  maintained 
by  the  continued  use  of  that  drug. 

This  is  the  situation  of  the  sufferer  from  addiction- 
disease  until  such  time  as  the  activity  of  his  addiction- 
disease  mechanism  is  arrested. 

Before  I  attempt  exposition  of  the  mechanism  which 
seems  to  me  best  to  explain  addiction-disease  and  offer  a 
basis  for  its  rational  handling,  I  shall  offer  several  ob- 
servations bearing  upon  physical  or  body  reaction  in  the 
state  of  addiction, 

1.  Experience  of  addicts  and  observations  upon  them 
show  that  the  length  of  time  over  which  an  addiction 
sufferer  is  free  from  his  ^^  withdrawal "  manifestations 
is  in  proportion  to  the   amount  he  has  recently  taken. 


NARCOTIC  DRUG  ADDICTION-DISEASE     33 

Under  conditions  eliminating  various  factors,  outside  of 
the  addiction  meclianism,  which  may  influence  this  gen- 
eral rule,  the  ratio  between  the  amount  of  recent  dosage 
and  the  interval  of  freedom  is  almost  mathematical.  Eor 
example,  if  under  given  conditions  one  grain  of  morphine 
will  keep  an  addict  free  from  withdrawal  manifestations 
for  four  hours,  two  grains  will  do  this  for  nearly  eight 
hours  and  three  will  have  the  same  effect  for  about  eleven 
hours.  It  would  almost  seem  as  if  there  were  some  sub- 
stance produced  in  definite  amount  in  each  individual 
case  at  a  given  time,  and  neutralized  or  opposed  by  or 
in  some  way  negatived  in  its  action  by  a  definite  amount 
of  opiate  drug. 

2.  Each  addict  shows  a  definite  and  approximately 
measurable  daily  minimum  need  for  the  drug  of  his  addic- 
tion. If  he  is  suffering  from  the  deprivation  of  his  drug, 
he  will  require  a  certain  dose,  measurable  by  its  effect 
upon  his  symptomatology,  before  he  is  made  physically 
comfortable  and  physically  efficient  again. 

3.  The  narcotic  drug  administered  to  an  addict  suffering 
withdrawal  phenomena  and  symptomatology  will  relieve 
those  manifestations  exactly  in  proportion  to  the  amounts 
of  drug  administered.  Each  addict  has  a  constant  se- 
quence of  symptoms  attending  the  so-called  "  dying-out '' 
of  the  drug.  These  symptoms  are  relieved  in  constant 
reverse  sequence  by  the  administration  of  the  drug,  and  in 
exact  proportion  to  the  amount  of  drug  administered, 
various  incidental  influences  being  eliminated.  A  small 
amount  of  the  opiate  will  relieve  the  symptoms  last  ap- 
pearing; another  insufficient  amount  will  relieve  another 
proportion  of  the  withdrawal  signs,  and  so  on,  until  the 
opiate  drug  administered  balances  in  amount  the  extent 
of  the  addict's  deprivation,  or  physical  need. 

This  is  almost  mathematical  in  its  working,  and  the 
average  intelligent  addict,  after  a  few  trials,  can  tell  within 
a  very  close  margin  just  how  much  opiate,  in  his  accus- 


34    THE  NARCOTIC  DRUG  PROBLEM 

tomed  form,  lias  been  administered  by  the  extent  to  wliich 
it  relieves  his  withdrawal  signs.  It  almost  seems  as  if  the 
narcotic  drug  acted  as  some  sort  of  an  antidote  for  some 
poison  present  in  definite  amounts  in  the  addict's  body. 


CHAPTER  lY 

THE    MECHAITISM    OF    NAECOTIO    DRUG-    ADDICTIOIir-DISEASE 

I  HAVE  in  previous  chapters  referred  to  what  are  known 
as  "withdrawal  signs.''  By  this  term  has  come  to  be 
known  the  manifestations  displayed  by  a  sufferer  from 
addiction-disease  at  such  times  as  his  opiate  is  taken  away 
or  "  withdrawn,"  either  totally  or  in  part  to  such  an 
extent  that  its  amount  does  not  meet  the  requirements  of 
his  physical  needs. 

In  observing  opiate  addicts  over  a  length  of  time  no 
one  can  escape  the  recognition  of  a  chain  of  constantly 
present  physical  manifestations  inevitably  following  the 
non-administration  of  the  drug  of  addiction.  These  may 
vary  in  priority  of  onset,  in  sequence,  and  in  relative 
violence  of  manifestation  in  different  cases,  but  they  are 
the  inevitable  result  of  non-administration  of  opiate  to 
an  opiate  addict.  I  described  them  as  follows  in  a  paper 
on  "  iN'arcotic  Addiction  —  A  Systemic  Disease  Condi- 
tion,'' which  was  published  in  the  Journal  of  the  American 
Medical  Association,  February  8,  1913.  "  In  a  general 
way  they  may  be  said  to  begin  with  a  vague  uneasiness 
and  restlessness  and  sense  of  depression ;  followed  by  yawn- 
ing, sneezing,  excessive  mucous  secretion,  sweating,  nausea, 
uncontrolled  vomiting  and  purging,  twitching  and  jerking, 
intense  cramps  and  pains,  abdominal  distress,  marked  cir- 
culatory and  cardiac  insufficiency  and  irregularity,  pulse 
going  from  extremes  of  slowness  to  extremes  of  rapidity 
with  loss  of  tone,  facies  drawn  and  haggard,  pallor  deep- 
ening to  greyness,  exhaustion,  collapse,  and  in  some  cases 
death." 

35 


36    THE  NARCOTIC  DRUG  PROBLEM 

These  manifestations  have  been  noted  in  various  ways 
and  to  various  extents  and  have  been  casually  commented 
upon  by  most  writers  of  the  past.  The  conception  of 
drug  addiction  as  a  "  habit "  has,  however,  in  the  past 
so  overwhelmingly  dominated  the  attitude  of  writers  both 
medical  and  lay,  that  consideration  of  withdrawal  signs  as 
physical  phenomena,  and  the  analysis  of  their  origin  and 
mechanism  on  the  basis  of  physical  disease  and  constant 
body  reaction  has  received  all  too  little  attention.  The 
tendency  has  been  to  casually  regard  or  belittle  them  as  a 
part  of  the  essential  picture  of  narcotic  addiction,  and  to 
place  overwhelming  emphasis  upon  mental  desire  as  an 
!}  explanation  of  the  drug  addict's  inability  to  discontinue 
the  administration  of  opiate  drugs.  That  these  physical 
manifestations  have  had  such  incidental  place  and  consid- 
eration in  the  general  handling  of  the  narcotic  addict  and 
in  the  consideration  of  the  drug  problem  is  to  my  mind  the 
basic  cause  for  past  failure.  I^on-appreciation  of  them 
unquestionably  explains  in  part  the  almost  uniform  lack  of 
success  which  attended  my  own  earliest  efforts. 

One  of  the  obstacles  to  an  appreciation  of  narcotic  drug 
addiction-disease  has  been  the  casual  assumption  on  the 
part  of  the  average  person,  both  lay  and  scientific,  that 
opiate  drugs  act  upon  the  addict,  and  that  he  reacts  to 
them  similarly  to  the  actions  and  reactions  in  the  non- 
addicted  individual.  Morphine  action,  however,  as  com- 
monly observed  following  therapeutic  administration  or  in 
experimentation  upon  un-addicted  animals  gives  no  con- 
ception of  its  manifestations  in  the  man  or  woman  grown 
tolerant  to  its  use.  Many  of  the  actions  and  reactions 
of  opiate  upon  the  un-addicted  are  practically  lost  in  the 
addicted,  and  absolutely  new  reactions,  unfound  in  the  un- 
addicted  individual,  become  the  dominating  factors  in  the 
opiate  medication  of  the  addict. 

To  some  extent  the  fallacies  connected  with  the  general 
conception  of  narcotic  addiction  have  arisen  from  the  mis- 


NARCOTIC  DRUG  ADDICTION-DISEASE      37 

taken  application  to  addicts  of  opiate  experience,  experi- 
mental or  otherwise,  of  the  non-addicted.  In  the  matter 
of  sensations,  for  example,  supposed  to  follow  opiate  ad- 
ministration, and  to  the  enjoyment  of  which  is  widely  at- 
tributed the  addict's  indulgence  —  in  practically  none  of 
the  opiate  addicts,  once  tolerance  and  organic  dependence 
are  completely  established,  do  these  sensations  occur.  The 
immediate  effect  of  opiate  to  the  addict,  depending  upon 
the  extent  of  tolerance,  and  the  reaction  of  the  patient,  in 
dosage  not  too  much  in  excess  of  physical  body  need,  is 
apparently  support  to  function,  the  restoration  or  main- 
taining of  normal  circulation  and  nerve  and  glandular 
balance,  prevention  or  relief  of  the  agonizing  withdrawal 
pains  and  manifestations  and  of  impending  collapse. 

Opiate  is  used  by  the  large  majority  of  opiate  addicts 
simply  and  solely  for  its  supportive  action,  and  a  certain 
amount  for  each  addict  becomes  as  much  of  a  definite  need 
and  a  necessary  and  integral  part  of  his  daily  sustenance 
as  food  or  air.  The  dream  states  and  other  sensuous 
results,  occasionally  observed,  are  when  they  occur  as  part 
of  the  minor  toxic  action  of  the  drug,  against  which  the 
developed  addict  is  nearly  or  completely  immune,  and  to 
the  experiencing  of  which  very  few  of  the  honest,  innocent 
or  accidental  addicts  have  ever  carried  their  dosage.  They 
are  commonly  found  only  in  the  opium  pipe  smokers,  an 
entirely  different  problem  from  that  of  the  average  nar- 
cotic addict. 

As  has  been  stated,  it  is  a  fact  that  for  each  addict,  a 
definite  amount,  varying  with  his  condition  of  health, 
elimination,  physical  and  mental  activity,  etc.,  meets  a 
definite  body-need.  On  this  amount  he  can  be  put  and 
kept  in  good  physical  and  mental  condition  under  normal 
circumstances  of  environment,  exertion,  and  general  hy- 
giene. Years  of  efiicient  activity  and  upright  responsible 
lives,  accomplished  by  well-known  men  and  women,  unsus- 
pected addicts,  bear  witness  to  this  fact.     An  addict  neither 


38  THE  NARCOTIC  DRUG  PROBLEM 

■Qiiderdosed  nor  overdosed  practically  defies  detection. 
Less  than  the  definite  amount  required  for  nervous  and 
glandular  and  circulatory  support  and  organic  balance  de- 
prives the  patient  of  reaction^  places  his  vitality  and  energy 
far  below  par  and  for  a  long  time  hinders  his  betterment. 
More  than  this  amount  displays  the  inhibitory  effects  of 
opiates,  locks  up  or  slows  secretions  and  body  functions, 
and  causes  malnutrition,  autotoxemia,  autotoxicosis,  and 
the  consequent  mental  and  physical  deterioration  com- 
monly and  erroneously  attributed  to  the  direct  action  of 
opiate  drug. 

In  1912  I  wrote  that  so  far  as  I  knew  the  sympto- 
matology attending  insufficient  supply  of  morphine  (or 
other  opiate)  to  an  opiate  addict  had  never  received  the 
amount  of  detailed  study  and  analysis  that  it  deserved 
and  was  not  adequately  interpreted.  W.  Marme  had  at- 
tributed the  symptoms  of  morphine  addiction  to  the  toxic 
action  of  oxydimorphine.  Rudolph  Kobert,  however, 
stated  that  Ludwig  Toth  subjected  Marme's  claims  to 
subsequent  testing  and  was  unable  to  confirm  them,  and 
that  his  own  findings  agreed  with  those  of  Toth.  They 
found  that  oxydimorphine  was  inert  by  subcutaneous  in- 
jection and  that  when  thrown  into  the  blood-stream  it 
formed  an  insoluble  substance  causing  emboli,  and  so  pro- 
ducing the  symptoms  observed  by  Marme.  Kobert  seems 
to  be  in  accord  with  the  early  findings  of  Magendie,  that 
oxydimorphine  is  non-toxic.  The  experiments  of  Faust 
on  dogs  concerning  increased  power  of  the  body  to  destroy 
morphine  are  well-known.  It  is  still  a  matter  of  scientific 
dispute  as  to  what  extent  the  body  of  the  opiate  addict  has 
developed  the  power  to  limit  or  destroy  the  poisonous  prop- 
erties of  opiates  by  the  conversion  of  these  poisons  through 
oxidation  or  other  chemical  action. 

The  explanation  of  tolerance  and  withdrawal  phenomena 
on  the  basis  of  something  akin  to  an  antitoxin  or  antitoxic 
substance  circulating  in  the  blood  of  the  addict,  has  also, 


NARCOTIC  DRUG  ADDICTION-DISEASE      39 

like  the  oxidation  explanation,  been  a  subject  of  contro- 
versy. Hirschlaff  claimed  to  have  produced  an  antitoxic 
serum  against  morphine.  Morgenroth  failed  to  confirm 
Hirschlaff's  findings,  and  argued  against  the  existence  of 
an  antitoxin.  The  animal  experimental  and  laboratory 
work  and  findings,  however,  of  such  men  as  Hirschlaff, 
Giofreddi  and  Valenti  have  helped  to  influence  the  trend  of 
modern  thought  towards  what  may  be  regarded  as  the 
present  strong  tendency  in  scientific  conception  of  the 
physical  mechanism  of  narcotic  drug  addiction-disease  — 
an  autogenous  antidotal  or  antitoxic  substance. 

A  recent  paper  by  DuMez  of  the  United  States  Public 
Health  Service  gives  a  comprehensive  review  of  the  work 
which  has  been  done  in  connection  with  the  study  of  in- 
creased tolerance  and  withdrawal  phenomena,  and  shows 
conclusively  the  gradual  inclination  of  modern  opinion. 

There  is  considerable  literature  discussing  various 
theories  and  experiments  and  observations,  which  has, 
however,  not  had  widespread  recognition. 

EEFEEENCES 

Bishop,  E.  S.,  "Narcotic  Addiction  —  A  Systemic  Disease 

Condition/'  Journal  A.  M.  A,,  Feb.  8,  1913. 
Marme,  W.,  "  Untersuchungen  zur  acuten  und  chronischen 

Morphinvergiftung/'  Deutch.  med.  Wchnschr.  9:  197- 

198. 
Kobert,  E.,  "  Lehrbuch  der  Intoxikationen/'  Stuttgart,  2;  995, 

1906. 
Toth,  L.,  "  Bemerkungen  zur  Erklarung  der  chronischen  Mor- 

phium  Intoxikation,''  Schmidt's  Jahrb.  329 :  135,  1891. 
Faust,  E.  S.,  "tJber  die  Uraschen  der  Gewohnung  an  Mor- 

phin ''  Arch,  f  exper.  Path.  u.  Pharmakol.  44 :  217-238, 

1900. 
Hirschlaff,  L.,  "  Ein  Heilserum  zur  Bekampfung  der  Morphin- 

sucht     und     Ahnlicher     Intoxikationen,''     Berl.     klin. 

Wchnschr.  39 :  1149-1152  and  1174-1177,  1902. 


40  THE  NARCOTIC  DRUG  PROBLEM 

Gioffredi,  C,  "  L'immunite  artificielle  par  les  alcaloides/'  28, 
402-407,  and  31,  fasc.  3,  1897. 

Valenti,  A.,  "  Experimentalle  Untersuchungen  liber  den 
chronischen  Morphinismus ;  Kreislanf  stomngen  hervorge- 
rufen  durch  das  Serum  morphinistscher  Tiere  in  der 
Abstinenzperiode,'^  Arch.  f.  exper.  Path  ti.  Pharmakol, 
75:  437-462,  1914. 

DuMez,  A.  G.,  "  Increased  Tolerance  and  Withdrawal  Phe- 
nomena in  Chronic  Morphinism,  A  Eeview  of  the  Lit- 
erature," Jour.  A.  M.  A.,  72 :  1069-1072,  1919. 

My  own  present  opinion  and  conception  remains  as  ex- 
pressed in  a  paper,  ^'  IsTarcotic  Addiction  —  A  Systemic 
Disease  Condition,"  written  in  1912  and  published  in  the 
Journal  of  the  American  Medical  Association,  Eeb.  8, 
1913,  as  follows,  "  It  is  my  opinion  that,  however  much 
increased  oxidation  aids  in  the  handling  of  morphine,  it 
is  to  the  formation  of  an  antitoxic  substance  that  we  must 
look  for  explanation  of  our  clinical  manifestations  and 
for  the  classification  of  morphine-addiction  as  a  definite 
medical  entity.  This  opinion  is  based  on  certain  clinical 
manifestations  of  morphine  effect  and  the  symptomatology 
attending  insufficient  supply  of  morphine  to  those  addicted, 
on  certain  phenomena  observed  during  and  following  treat- 
ment, on  the  persistence  of  tolerance  and  on  the  suscepti- 
bility of  the  cured  patient  to  the  re-formation  of  addic- 
tion.'" 

Before  elaborating  this  conception  of  addiction-disease, 
I  think  it  desirable  to  repeat  the  enumeration  of  the  prin- 
cipal manifestations  of  ^^  withdrawal  "  or  body-need  for 
opiate  drug.  In  a  general  way,  they  may  be  said  to  begin 
with  a  vague  uneasiness  and  restlessness  and  sense  of  de- 
pression and  weakness;  followed  by  yawning,  sneezing, 
sweating,  excessive  mucous  secretion,  nausea,  uncontroll- 
able vomiting  and  purging  or  diarrhea,  twitching  and 
jerking,  sometimes  violent  jactitation,  intense  muscular 
cramps  and  pains  (described  as  if  the  flesh  were  being 


NARCOTIC  DRUG  ADDICTION-DISEASE      41 

torn  from  the  bones  )^  abdominal  pain  and  distress,  marked 
cardiac  and  circulatory  insufficiency,  and  irregularity 
(often  with  marked  dyspnea),  pulse  going  from  extremes 
of  slowness  to  extremes  of  rapidity,  with  lowered  blood- 
pressure  and  loss  of  tone,  f  acies  drawn  and  haggard,  pallor 
deepening  to  greyness,  exhaustion,  collapse  and  in  some 
cases,  death. 

Essential  Mechanism  of  Narcotic  Drug  AddictionrDisease 

If  such  clean-cut,  strikingly  apparent,  constant,  and  un- 
deniably physical  phenomena  and  symptomatology  as  I 
have  described  are  to  be  adequately  explained,  there  must 
be  some  physical  mechanism,  some  definite  body  process 
working  upon  fundamental  principles  of  disease  reaction. 
They  certainly  are  not  psychiatric  manifestations  nor  the 
expressions  of  habit,  appetite,  vice,  nor  morbid  indulgence. 
Enjoyment  of  morphine  for  itself,  even  in  such  patients  as 
have  ever  experienced  such  enjoyment,  is  lost  long  before 
the  stage  of  rooted  or  completely  developed  addiction  is 
reached.  Physical  results  must  be  explained  by  physical 
cause. 

Tolerance  of  and  immunity  to  the  toxic  effects  of  nar- 
cotic drugs  are  primary  and  striking  characteristics  in 
the  development  of  addiction.  An  antitoxin  or  antidotal 
substance  is  the  recognized  mechanism  of  their  production 
in  most  diseases  admittedly  developing  these  characteris- 
tics. I  have  adopted  the  hypothesis,  therefore,  that  an 
antidotal  substance  is  manufactured  by  the  body  as  a  pro- 
•tection  against  the  poisonous  effects  of  narcotic  drugs  con- 
stantly administered.  Such  a  substance,  manufactured  in 
the  body,  being  antidotal  to  morphine,  might  well  possess 
toxic  properties  of  its  own,  exactly  opposite  in  manifesta- 
tion to  those  possessed  by  morphine  and  other  opiates. 
Toxic  substances  exactly  opposite  to  opiate  in  their  action 
might  readily  account  for  the  severe  withdrawal  signs, 
parallel  in  their  extent  to  the  extent  of  opiate  insufficiency. 


42  THE  NARCOTIC  DRUG  PROBLEM 

and  resembling  in  their  characteristics  the  manifestations 
of  acute  poisoning. 

A  hypothetical  antidotal  toxic  substance,  manufactured 
by  the  body  as  a  protection  against  the  toxic  effects  of  con- 
tinued administration  of  an  opiate  drug,  will  therefore  ex- 
plain the  well-known  development  of  tolerance  and  im- 
munity in  these  cases,  and  will  account  for  the  violent 
physical  withdrawal  signs.  In  a  word,  it  will  explain  the 
disease  fundamentals  on  a  definite  physical  basis. 

Such  an  hypothesis  will  explain  the  stages  of  develop- 
ment of  addiction  before  outlined.  In  the  stage  of  toler- 
ance the  antidotal  toxic  substance  has  begun  to  make  its 
appearance  in  the  body  and  to  protect  it  against  slight 
narcotic  excess,  but  its  manufacture  is  not  sufficientlv 
established  to  continue  longer  than  necessary  to  neutralize 
the  narcotic  administered.  In  the  stage  of  beginning  ad- 
diction, or  beginning  narcotic-need,  its  manufacture  has 
become  more  developed  and  more  constant  and  proceeds  for 
a  longer  time  after  the  discontinuance  of  the  narcotic  drug. 
In  the  stage  of  fully  developed  addiction,  or  absolute  nar- 
cotic need,  the  manufacture  of  the  antidotal  toxic  substance 
has  become  practically  an  established  pseudo-physiological 
body-process,  and  will  continue  long  after  the  administra- 
tion of  the  narcotic  drug  for  reasons  into  which  I  have 
gone  elsewhere.  In  other  words,  in  narcotic  drug  addic- 
tion some  antidotal  toxic  substance  has  become  the  con- 
stantly present  poison,  and  the  narcotic  drug  itself  has 
become  simply  the  antidote  demanded  for  its  control  In 
brief,  fundamentally  and  basically,  narcotic  drug  addiction 
is  a  condition  presenting  definite  physical  phenomena, 
symptoms,  and  signs,  due  to  the  presence  within  the  body 
of  some  autogenous  poison  requiring  narcotic  drug  for 
neutralization  of  it  or  of  its  effects. 

This  explains  the  phenomena  of  the  mathematical  ex- 
actness with  which  the  minimum  daily  need  can  be  esti- 
mated under  experimental  conditions,  and  with  which  doses 


NARCOTIC  DRUG  ADDICTION-DISEASE      43 

less  than  the  amount  of  actual  body  need  relieve  existing 
withdrawal  signs  in  definite  proportion  to  the  amount  of 
opiate  administered.  In  exact  proportion  as  the  drug  of 
addiction  is  present  in  the  body  to  neutralize  or  oppose 
some  antidotal  poison,  is  the  patient  free  from  withdrawal 
symptoms  and  from  physical  craving  for  the  narcotic  drug. 

The  development  and  existence  of  such  mechanism  in  the 
body  of  the  opiate  addict  is  suggested  also  by  the  apparent 
continuance  of  tolerance  to  opiate  existing  after  long  pe- 
riods without  drug  in  individuals  who  had  previously  suf- 
fered from  addiction-disease,  and  in  the  susceptibility  of 
the  former  sufferer  subsequent  to  the  arrest  of  his  physical 
need  for  opiate,  to  the  re-establishment  of  that  need  by  the 
subsequent  administration  of  the  drug. 

Illustrative  of  this  phenomenon  is  a  case  who,  after 
about  two  years  of  relief  from  addiction-disease,  developed 
pneumonia  and  to  whom  in  delirium  and  threatened  death, 
opiates  were  administered  as  unavoidable  medication. 
After  cessation  of  his  delirium,  he  was  dismayed  to  dis- 
cover addiction-manifestations  and  body-need  for  opiate 
drug  had  been  re-established.  This  history  is  one  of  a 
number  in  my  possession,  and  has  been  verified. 

The  case  demonstrating  the  longest  persistence  of  sus- 
ceptibility among  my  records,  is  that  of  a  man  in  the  early 
fifties  who  underwent  an  emergency  operation  for  infected 
gall-bladder.  A  day  or  two  following  operation  he  de- 
veloped excruciating  pain  in  his  right  side  just  under  the 
ribs.  It  had  been  necessary  to  administer  opiates  since  a 
day  or  two  before  the  operation.  I  was  called  in  consulta- 
tion for  the  purpose  of  determining  the  character  and 
origin  of  the  pain,  and  diagnosed  a  pleurisy,  the  pain  of 
which  subsided  on  the  following  day.  Opiates  were  dis- 
continued with  a  result  of  precipitating  unmistakable 
withdrawal  phenomena.  To  his  great  anger  and  surprise, 
I  accused  the  patient  of  being  an  opiate  addict.  He  in- 
dignantly declared  that  he  had  never  used  opiates  in  his 


44     THE  NARCOTIC  DRUG  PROBLEM 

life.  Subsequent  investigation  with  tlie  aid  of  older  mem- 
bers of  bis  family  disclosed  a  distinct  and  typical  history 
of  addiction  manifestations  following  opiate  administration 
in  the  course  of  treatment  of  a  complicated  fracture  of 
bis  thigh  in  early  boyhood.  The  drug  had  been  withdrawn 
at  that  time  and  the  addiction  manifestations  finally  dis- 
appeared, he  never  having  been  aware  of  the  facts.  His 
reawakened  addiction-manifestations  were  easily  and 
quickly  checked. 

It  is  evident  from  many  histories  that  large  dosage 
robbed  of  or  modified  in  its  toxic  effect,  and  even  in  the 
opiate  manifestations  usual  in  subjects  who  have  never 
been  made  tolerant,  and  small  dosage  being  sufficient  to 
re-awaken  physical  need  for  opiates  are  conditions  which 
do  exist  and  persist  for  indefinite  periods.  The  resem- 
blance between  this  continued  tolerance  and  the  conditions 
existing  in  diseases  which  confer  immunity  and  having  a 
generally  accepted  antitoxin  mechanism  is  too  close  to  be 
ignored. 

Evidence  of  a  toxic  substance  in  the  body  of  a  narcotic- 
addict  is  further  presented  by  the  similarity  of  the  clinical 
pictures  presented  by  these  cases  of  acute  opiate  need  and 
extremely  severe  cases  of  acute  poisoning  from  materials 
such  as  the  ptomains  and  some  other  poisons.  Acute 
opiate  need  is  clinically  typical  of  intense  suffering  and 
prostration  from  the  action  of  some  powerful  poison.  Its 
symptoms  cannot  be  due  to  opiate,  for  the  reason  that  the 
administration  of  opiate  relieves  them,  and  relieves  them 
exactly  in  ratio  to  the  amount  of  opiate  administered. 
They  can  be  held  at  any  given  stage  by  gradation  of  the 
opiate  dosage.  Their  manifestations,  moreover,  are  ex- 
actly opposite  to  opiate  effect.  They  are  to  my  mind  best 
explained  as  due  to  the  action  of  some  toxic  substance, 
antidotal  to  opiate,  prepared  by  the  body  for  its  protection 
in  response  to  continued  opiate  presence  in  the  body,  as 
antitoxins  are  prepared  for  the  neutralization  of  or  opposi- 


NARCOTIC  DRUG  ADDICTION-DISEASE      45 

tion  to  the  organic  poisons  of  invading  bacteria.  The 
chemical  or  physical  character  or  nature  of  such  substance 
has  not  been  yet  determined. 

The  presence  of  such  a  substance  would  explain  the 
establishing  of  tolerance,  the  manifestations  following 
opiate  administration  and  the  apparent  definiteness  of  the 
amount  of  opiate  needed.  It  would  explain  the  results 
of  under-dosage  and  the  results  of  over-dosage,  and  the 
practical  non-interference  with  function  or  general  health 
when  a  dosage  is  maintained  exactly  sufficient  in  amount 
to  neutralize  the  effect  of  some  exactly  antidotal  body  or 
substance. 

An  antidotal  substance  would  also  explain  the  after 
effects  of  and  the  so-called  "  relapses  "  which  occur  after 
most  of  the  cases  treated  by  whatever  method  or  proced- 
ure, without  due  appreciation  and  proper  estimation  of  the 
clinical  manifestations  and  indications  of  addiction  symp- 
toms and  physical  body  need,  and  without  due  considera- 
tion of  the  patient's  reactive  abilities  and  physical  con- 
dition. These  patients  are  in  a  condition  of  restlessness, 
discomfort,  vague  pains,  mental  and  physical  depression, 
lowered  physical  vitality  and  weakness.  They  have  a 
sense  of  a  physical  lack  of  support.  They  cannt)t  endure 
nor  react  to  over-exertion,  worry,  strain,  etc.  This  con- 
dition may  persist  for  weeks  and  months  after  no  opiate 
has  been  administered.  The  above  seem  to  be  mild  with- 
drawal symptoms  of  an  incompletely  arrested  addiction- 
disease  mechanism  and  might  be  explained  by  a  continued 
manufacture  of  small  amounts  of  antidotal  toxic  substance, 
causing  a  low  grade  chronic  poisoning.  They  can  be  du- 
plicated in  active  opiate  addiction  before  withdrawal  by 
administering  an  amount  of  opiate  slightly  below  the 
amount  of  need  and  so  leaving  unneutralized  a  small 
amount  of  the  antidotal  toxic  substance. 

If  continued  production  of  a  toxic  antidotal  substance, 
after  discontinuance  of  the  drug  which  called  it  into  being 


46    THE  NARCOTIC  DRUG  PROBLEM 

is  to  explain  the  existence  of  the  condition  I  have  just 
described,  the  causation  of  this  continued  production  must 
be  accounted  for.  It  is  conceivable  that  in  the  develop- 
ment of  addiction-disease  mechanism  a  tolerance  of  and 
slowness  to  eliminate  opiate  or  some  product  of  opiate  is 
acquired  by  all  the  cells  of  the  body,  perhaps  especially  by 
the  liver,  and  that  these  tolerant  and  atonic  cells  are  ex- 
tremely slow  of  opiate  elimination.  Under  this  condition, 
a  residue  of  opiate  or  some  product  of  opiate  capable  of 
antidotal  substance  stimulation  might  remain  unrespon- 
sive, or  very  slow  of  response,  to  ordinary  cellular  and 
other  elimination.  If  this  should  prove  to  be  the  fact, 
it  would  account  for  a  continued  production  of  antidotal 
toxic  substance,  and  might,  moreover,  in  any  given  case, 
either  before  or  after  cessation  of  opiate  medication,  be 
one  of  the  determining  factors  in  the  amount  of  antidotal 
substance  produced,  or,  in  other  words,  in  the  measure  of 
the  extent  of  body-need  for  opiate  drug. 

Inhibition  of  Function 

What  characteristic  action  exists  in  opiate  or  narcotic 
drugs  which  gives  them  this  power  to  establish  the  above 
described  mechanism  ?  It  seems  to  me  that  it  is,  above  all, 
their  power  to  inhibit  body  function.  They  tend  mark- 
edly to  arrest  metabolic  processes.  They  inhibit  glandu- 
lar activity.  They  inhibit  unstriped  muscle  activity  and 
hence  peristalsis.  They,  therefore,  cause  a  slowing  up  of 
glandular  function  and  intestinal  activity,  and  of  elimina- 
tion. This  results  in  an  accumulation  of  opiate  in  the 
body.  It  is  this  constant  accumulation  to  which  the  body 
must  become  tolerant  by  the  development  of  some  me- 
chanism for  its  protection. 

Autointoxication  and  Autotoxicosis 

It  is  to  the  element  of  inhibition  of  function  also  that 
we  must  look  for  explanation  of  what  is  by  far  the  most 


NARCOTIC  DRUG  ADDICTION-DISEASE     47 

important  element  in  the  immediate  picture  presented  by 
most  individual  cases.  I  refer  to  autotoxicosis  and 
to  auto-  and  intestinal  toxemia.  The  same  power  that 
locks  up  within  the  body  the  opiate  drug,  locks  up  the 
toxic  products  of  tissue  activity  and  tissue  waste,  of  in- 
testinal poisons  and  of  insufficient  metabolism.  Auto- 
toxemia  itself  is  markedly  inhibitory  in  its  action,  and 
contributes  no  little  to  its  own  increase  and  to  the  further 
development  of  narcotic  disease. 

It  is  not  at  all  impossible  that  any  inhibiting  poison 
constantly  present  in  the  body  will  some  day  be  found  to 
establish  a  mechanism  of  protection,  similar  to  that  of 
opiate  addiction,  and  that  some  of  the  states  now  popularly 
and  loosely  classified  under  the  general  head  of  "  autoin- 
toxications "  will  be  recognized  as  really  addiction-states, 
in  which  the  body  has  become  progressively  tolerant  of  its 
own  poisons.  I  believe  that  it  can  be  demonstrated  that 
some  of  the  phenomena  and  manifestations  at  times  ob- 
served in  chronically  inhibited  and  autotoxic  individuals 
in  whom  there  can  be  no  suspicion  of  any  opiate  or  nar- 
cotic element  are  analogous  to  the  phenomena  of  narcotic 
addiction  mechanism.  It  is  not  inconceivable  that  any 
inhibiting  poison  or  toxin  is  capable  of  producing  its  own 
addiction-mechanism,  and  it  has  seemed  to  me  that  my  own 
clinical  familiarity  with  the  action  and  reaction  of  nar- 
cotic, inhibiting,  or  addiction-forming  drugs  and  of  ad- 
diction-mechanism upon  circulation,  glandular  and  intes- 
tinal and  other  function  has  been  of  no  little  assistance 
in  the  interpretation,  control  and  remedy  of  other  chronic 
intoxications. 

Upon  the  extent  of  inhibition  of  function  and  autoin- 
toxication, therefore,  depend  some  of  the  immediately  pre- 
dominating manifestations  in  individual  cases.  They 
must  be  reckoned  with  and  eliminated  in  the  measure  of 
addiction-disease  in  the  individual  sufferer.  In  many 
cases  they  contribute  the  immediate  and  compelling  in- 


48    THE  NARCOTIC  DRUG  PROBLEM 

dications  for  rational  therapeutic  endeavor.  To  a  con- 
siderable extent  they  determine  circulatory  efficiency  and 
metabolic  and  glandular  activity  and  balance.  They 
largely  control  physical  tone  and  physical  reaction.  In- 
hibition and  intestinal  and  autotoxemia  cause  most  of 
the  physical  and  mental  deterioration,  and  much  of  the 
incidental  symptomatology  so  widely  ascribed  directly  to 
narcotic  drug  effect.  Upon  the  extent  of  their  presence, 
therefore,  depends  greatly  the  clinical  picture  in  the  in- 
dividual case.  This  doubtless  accounts  for  the  acidosis, 
noted  by  Jennings  and  others,  inasmuch  as  it  has  been 
definitely  proved  that  acidosis  is  commonly  present  in  all 
conditions  of  functional  depression  and  exhaustion. 

With  inhibition  and  auto  and  other  toxemia  eliminated 
or  reduced  to  a  minimum,  the  patient  can  go  through  many 
years,  an  apparent  normal  man,  well-nourished,  reactive, 
in  good  physical  tone,  mentally  sane  and  physically  com- 
petent. Under  these  conditions  he  shows  practically  noth- 
ing abnormal  as  long  as  he  gets  properly  administered, 
his  accustomed  narcotic  drug,  in  the  amount  of  its  min- 
imum physical  requirement  or  body-need.  His  condition 
is  often  unsuspected  by  those  nearest  and  dearest  to  him, 
and  the  popularly  held  opinion  that  narcotic  addiction 
shortens  life  does  not  seem  to  be  upheld  by  the  facts  in 
his  case.  Such  cases  as  his  are  far  more  numerous  than 
has  as  yet  been  realized. 

In  the  types  of  narcotic  addicts  most  widely  recognized 
inhibition  of  function  and  autointoxication  is  marked,  and 
the  opiate  drug  is  used  in  excess  of  body-need.  The  ad- 
dict of  this  description  becomes  a  deteriorated  wreck,  re- 
quiring high  doses  of  opiate  for  the  satisfaction  of  abnor- 
mal body-need,  mentally  and  physically  incompetent  — 
the  generally  accepted  picture  of  the  so-called  "  dope- 
fiend,"  a  deteriorated,  degenerated,  malnourished  wretch, 
degraded,  avoided  and  condemned. 

Inhibition  of  function  and  autointoxication  should  not 


NARCOTIC  DRUG  ADDICTION-DISEASE      49 

be  vague  terms.  They  cause  and  are  measurable  by 
definite  clinical  evidence.  They  display  manifest  phe- 
nomena and  symptoms,  and  become  increasingly  defined 
material  entities  as  the  clinician  looks  for  them  as  such. 
Much  of  inhibition  of  function  and  autointoxication  and 
of  their  manifestations,  has  been  recognized  and  taught 
under  their  own  heading  and  in  connection  with  condi- 
tions other  than  narcotic  drug  addiction-disease.  That 
the  influence  and  importance  of  inhibition  of  function 
and  autointoxication  in  the  development,  and  manifesta- 
tions of  the  narcotic  drug  addict  has  escaped  general  and 
widespread  recognition,  is  evidence  of  the  small  amount 
of  unbiased  clinical  study,  and  of  analytical  clinical  in- 
terpretation of  material  physical  phenomena,  hitherto  ac- 
corded to  narcotic  drug  cases. 

I  would  not  have  it  concluded  that  all  symptoms  and 
manifestations  arising  in  the  handling  of  a  drug  addict 
are  due  to  the  factors  and  elements  I  have  discussed  in 
this  chapter.  It  must  be  always  in  the  mind  of  the  in- 
telligent and  conscientious  physician,  that  he  has  in  his 
care  a  human  being  with  the  same  medical  and  psychical 
possibilities  that  must  be  taken  into  careful  and  complete 
account,  as  in  the  handling  of  any  other  sick  person. 
There  is  an  unfortunate  tendency  to  overlook  concurrent, 
or  complicating  or  pre-existing  conditions  in  the  handling 
of  the  narcotic  drug  addict.  These  cases  are  often  ex- 
tremely complex  and  difficult  to  analyze,  and  for  adequate 
comprehension  and  handling  of  them,  the  symptoms  and 
manifestations  they  show  should  be  appreciated  in  their 
true  origin  and  character  as  they  occur  in  each  individual 
case. 


CHAPTER  V 

EEMAEXS   ON   METHODS   OF   TBEATIl^G   NAKCOTIC   DETJG 

ADDICTION 

Most  physicians  have  at  some  time  or  other  in  the 
course  of  their  practice  encountered  cases  of  narcotic  ad- 
diction. Most  addicts  have  appealed  to  the  physician  for 
advice  and  help.  A  very  large  proportion  of  them  have 
at  different  times  made  effort  to  obtain  relief  from  their 
affliction  through  the  avenues  of  various  forms  of  treat- 
ment, advertised  and  otherwise.  Most  physicians  have  at 
some  time  or  other  made  effort  to  rescue  some  victim 
from  drug  addiction,  and  as  a  rule  have  given  over  the 
effort  as  hopeless,  because  even  when  they  had  succeeded 
in  taking  his  narcotic  away  from  the  patient,  usually 
after  an  experience  trying  and  exhausting  to  both,  the 
patient  has  resumed  narcotic  administration  —  according 
to  the  patient,  because  he  had  to  —  according  to  the  aver- 
age observer,  because  he  wanted  to.  Frequently  the  pa- 
tient has  refused  to  persevere  to  the  end  of  treatment  and 
has  abandoned  his  attempts  before  the  treatment  has 
reached  the  point  of  cessation  of  opiate  medication  —  the 
patient  stating  that  he  could  not  —  the  observer  believing 
that  he  would  not,  continue,  and  did  not  have  the  cour- 
age or  stamina  or  will  to  endure  the  necessary  suffering. 
The  medical  profession  as  a  whole  has  adopted  a  cynical 
attitude  towards  the  possibility  of  permanent  "  cure," 
and  towards  the  efficacy  of  medical  treatment,  which  has 
tended  to  send  the  addict  to  quacks  and  charlatans  and 
various  advertised  remedies. 

It  is  not  my  purpose  to  discuss  in  this  book  in  detail 

50 


TREATING  NARCOTIC  DRUG  ADDICTION      51 

the  various  methods,  and  treatments  and  cures  advocated 
and  employed  in  the  handling  of  the  drug  addict.  This 
alone  would  require  a  volume  in  itself. 

Three  broad  lines  of  procedure  have  been  employed; 
so-called  ^^  slow-reduction/'  "  sudden  withdrawal,"  and 
withdrawal  accompanied  by  the  administration  of  various 
drugs,  such  as  those  in  the  belladonna  group  and  its 
alkaloids. 

Slow  reduction  or  "  gradual  reduction  "  as  a  "  method  " 
is  employed  by  slowly  or  gradually  reducing  the  patient's 
accustomed  dosage  to  the  point  of  discontinuance  of  opiate 
medication.  Interpreted  by  a  great  many  to  mean  that 
the  fact  of  reduction  is  the  principal  indication  in  clin- 
ical procedure,  successful  in  the  hands  of  a  few  who  have 
acquired  unusual  technical  skill  and  clinical  ability  in 
the  interpretation  of  addiction  manifestations,  I  believe 
it  to  have  failed  as  a  method  of  cure  in  the  hands  of  the 
average.  Practically  every  addict  has  attempted  it  one 
or  more  times.  As  a  method  of  procedure  in  some  stages 
and  under  some  conditions  of  addiction  treatment,  slow 
or  gradual  reduction  of  dosage  has  its  value.  In  my  opin- 
ion, however,  all  other  considerations  aside,  there  are  very 
few  who  are  possessed  of  sufficient  understanding  of  nar- 
cotic addiction  and  ability  in  the  interpretation  of  clinical 
indications,  and  have  the  technical  skill  required  to  carry 
it  through  to  a  clinically  successful  culmination.  As  a 
method  of  routine  or  forcible  application  it  has  many 
serious  objections  as  well  as  potentialities  for  damage  to 
the  patient.  In  cases  whose  opiate  intake  is  in  excess  of 
actual  physical-need,  gradual  reduction  as  often  practiced 
is  perfectly  easy  and  unnecessarily  slow  down  to  the 
amount  demanded  as  a  minimum  by  the  patient's  addiction- 
disease  requirements  Then  must  come  withdrawal,  nag- 
ging, exhausting  and  protracted,  if  unskillful  reduction 
is  persisted  in,  and  the  wrench  of  actual  final  withdrawal 
is  nearly  as  severe  from  a  very  small  dosage  as  from  a 


52     THE  NARCOTIC  DRUG  PROBLEM 

moderate  one,  other  conditions  in  tlie  case,  physical  and 
mental,  being  equal.  Prolonged  "  withdrawal  "  without 
rare  technical  skill  and  without  unusual  and  not  com- 
monly available  environment  and  conditions  of  life,  means 
subjecting  the  patient  to  the  continued  strain  of  persistent 
self-denial  and  self-control  in  the  face  of  continued  suf- 
fering, discomfort,  and  physical  need  and  constant  desire 
for  their  relief.  It  is  my  opinion  that  this  experience 
has  in  many  cases  tended  to  deeply  impress  upon  the  mind 
of  the  patient  so-called  "  craving  "  for  the  drug,  and  has 
converted  many  a  case  of  simple  physical  addiction-dis- 
ease into  a  more  or  less  mental  state  which  may  be  de- 
scribed as  "  morphinomania  "  or  "  narcomania." 

This  last  observation  does  not  apply  to  the  method  of 
gradual  reduction  only,  but  is  equally  true  of  protracted 
suffering  under  any  other  procedure  in  which  the  in- 
dividual is  cognizant  of  the  existence  of  means  of  im- 
mediate if  only  temporary  relief. 

In  the  comprehension  of  this  a  physician  has  only  to 
glance  back  over  his  professional  experience  and  recall 
cases  of  various  conditions  other  than  addiction  which 
have  come  to  him,  and  whose  histories  present  the  effect 
of  long  protracted  suffering  and  discomfort  in  the  con- 
version of  an  average  normal,  self-supporting  human  being 
into  a  dependent  neurasthenic. 

The  histories  given  by  most  narcotic  addicts  of  their 
efforts  to  get  relieved  of  addiction,  show  that  following  the 
withdrawal  of  opiate  drug  in  many  if  not  most  instances 
has  come  weeks  and  months  of  weakness,  and  discomfort, 
nervousness,  sleeplessness,  and  pain  which  have  persisted 
for  weeks  and  months,  establishing  the  basis  for  the  much 
emphasized  "  after  care,"  of  some  investigators. 

While  so-called  "  after  care  "  is  unquestionably  as  im- 
portant as  convalescence  from  any  other  disease,  it  is  my 
belief  that  as  understanding  of  addiction  as  a  clinical  dis- 
ease becomes  more  general,   and  more  attention  is  paid 


TREATING  NARCOTIC  DRUG  ADDICTION      53 

to  the  study  and  scientific  management  of  the  disease  it- 
self, the  stage  of  "  after  care  "  will  come  to  assume  less 
importance.  Addiction  is  not  the  only  disease  which 
furnishes  examples  of  cases  in  which  incomplete  and  un- 
satisfactory results  have  been  merely  a  low-grade  con- 
tinuation of  the  fundamental  disease  and  have  been  in- 
terpreted as  a  protracted  convalescence. 

"  After  care,"  or  convalescence,  following  satisfactory 
results  of  clinical  treatment  and  complete  arrest  of  ad- 
diction-mechanism activity  has  no  terrors  for  either 
physician  or  patient.  It  is  very  short  and  does  not  re- 
quire any  more  restraint  than  any  other  convalescence, 
unless  conditions  exist  following  active  treatment  which 
should  have  been  recognized  and  handled  and  eliminated 
earlier  from  the  picture.     I  shall  discuss  this  again  later. 

"  Sudden  "  or  "  forcible  "  withdrawal,  or  immediate 
deprivation  of  opiate  drug  is  still  advocated  by  some  in- 
vestigators, fewer  and  fewer  of  them,  however,  among 
medical  men.  There  are  cases  of,  and  stages  in  addiction- 
disease  and  its  development  where  this  means  of  pro- 
cedure may  be  pursued  without  all  of  the  serious  objec- 
tions with  which  it  must  be  regarded  as  a  routine  method 
of  general  enforcement. 

That  forcible  deprivation  of  opiate  drug  may  end  in 
death  is  a  matter  of  too  easily  found  and  authoritative 
medical  record  to  be  ignored.  It  has  been  discussed  as 
one  of  the  possibilities  by  medical  writers  over  many  years. 
Even  the  newspaper  reports  of  deaths  and  suicides  fol- 
lowing sudden  deprivation  of  opiate  should  be  sufficient 
to  give  pause  to  those  who  would  still  advocate  this  meas- 
ure as  a  desirable  procedure. 

Reference  to  the  previous  enumerations  of  the  physical 
manifestations  of  body-need  for  opiate,  or  '^  withdrawal 
signs,"  should  be  sufficient  for  the  comprehension  of  its 
tortures  and  easily  explains  the  suicides  which  have  at- 
tended sudden  deprivation.     Any  one  who  has  watched  a 


64    THE  NARCOTIC  DRUG  PROBLEM 

well-developed  case  of  addiction-disease  in  the  agonies  of 
opiate  deprivation  should  hesitate  to  prolong  them  if  pos- 
sibly avoidable.  While  under  some  conditions,  and  in 
some  cases,  it  may  be  argued  that  ^'  the  ends  will  justify 
any  means/'  as  a  routine  procedure  of  wide  application, 
it  must  be  stated  that  both  in  its  immediate  torment  and 
in  its  end  results,  mere  forcible  sudden  withdrawal  is  not 
a  procedure  of  election.  Some  of  its  supporters  still  cling 
to  and  quote  the  old  fallacy  that  after  seventy-two  hours 
without  opiate  a  narcotic  addict  no  longer  physically  re- 
quires it.  This  fallacy  is  probably  based  upon  the  esti- 
mated maximum  time  of  opiate  elimination  in  normal 
human  beings  and  experimental  animals.  It  is  most  de- 
cidedly false  doctrine  as  applied  to  the  well-developed 
case  of  addiction-disease  in  whom  the  mechanism  of  dis- 
ease, and  not  the  mere  administration  or  elimination  of 
opiate  has  become  what  should  be  the  dominating  con- 
sideration. 

As  stated  before,  the  mere  withdrawal  of  opiate  drug 
does  not  arrest  the  activity  of  addiction-disease,  nor  pre- 
vent the  endurance  of  the  exhausting  and  incapacitating 
and  protracted  low-grade  manifestations  before  referred  to. 
Its  potentialities  of  permanent  damage,  moreover,  are 
attested  by  and  displayed  by  many  who  show  for  years 
shattered  nerves,  premature  old  age,  etc. 

It  is  perhaps  wise  to  state  again  in  this  place  that  in 
this  book  the  consideration  of  narcotic  or  opiate  addiction, 
its  mechanism  symptomatology  and  handling,  is  not  to 
be  applied  to  cocaine  and  alcohol  use  nor  to  the  various 
other  drugs  often  loosely  grouped  with  opiates  as  "  habit- 
forming."  Until  a  distinct  physical  disease  mechanism, 
attended  by  analogous  characteristic  and  constant  physical 
phenomena,  can  be  demonstrated  as  resulting  from  the 
action  of  one  of  these  drugs  or  substances,  its  continued 
use  should  not  be  classed  with  opiate  addiction-disease. 

The  third  general  method  of  procedure  is  that  in  which 


TREATING  NARCOTIC  DRUG  ADDICTION      55 

effort  is  made  to  utilize  other  drugs  tlian  opiates,  or  other 
measures  than  mere  reduction  or  withdrawal  or  depriva- 
tion to  secure  cessation  of  opiate  medication.  The  efforts 
have  been,  in  a  general  plan,  either  to  oppose  or  replace 
the  action  of  opiate  by  substance  or  substances  seemingly 
to  have  physiologically  antagonistic  or  substitution  proper- 
ties —  or  to  combat,  offset  or  benumb  the  sufferings  of 
what  is  described  as  the  "  withdrawal  period/'  Such 
agents  have  been  employed  in  this  disease  for  very  many 
years,  and  in  their  variety  include  most  of  the  known 
analgesic,  sedative,  antispasmodic,  hypnotic  or  anesthetic 
agents  and  measures. 

Prominent  among  the  drugs  mentioned  have  been  the 
preparations  and  alkaloids  of  belladonna,  of  hyoscyamus, 
pilocarpine,  and  some  others.  These  drugs  have  by  rea- 
son of  more  or  less  supposed  specific  action,  alone,  or  in 
various  combinations  or  in  conjunction  with  purgatives, 
etc.,  formed  the  basis  for  many  if  not  most  of  the  various 
special  treatments  and  "  cures.''  For  example,  what  is  de- 
scribed as  the  ^^  specific  mixture "  of  one  of  the  most 
widely-known  treatments  contains  as  its  active  agents 
belladonna  and  hyoscyamus.  These  drugs  are  not  men- 
tioned here  in  condemnation  of  their  employment  as  ther- 
apeutic measures  in  the  hands  of  those  skilled  in  the  es- 
timation of  their  values,  indications  and  actions  —  and 
dangers  if  unskillfuUy  employed.  They  have  unques- 
tioned therapeutic  value  in  their  proper  places,  as  and 
when  properly  indicated,  in  individual  cases.  Routinely 
used,  as  specific  curative  agents,  they  seem  to  me  to  be 
demonstrating  their  failure.  In  the  conception  of  addic- 
tion-disease herein  outlined  it  is  difficult  to  attribute  to 
them  specific  properties. 

In  a  paper,  ^'  The  Rational  Handling  of  the  Narcotic 
Addict "  read  before  the  Section  on  Pharmacology  and 
Therapeutics,  Annual  Session  of  the  American  Medical 
Association,  1916,  I  stated,  "  It  is  not  my  purpose  to  en- 


66     THE  NARCOTIC  DRUG  PROBLEM 

ter  into  discussion  of  the  various  therapeutic  methods  and 
therapeutic  measures  which  have  been  advocated  and  em- 
ployed in  the  treatment  of  narcotic  addiction.  Their 
number  is  legion,  and  they  include  most  of  the  therapies 
known  to  lay  as  well  as  to  medical  literature. 

"  Their  multitude  is  conclusive  proof  of  lack  of  concep- 
tion and  of  understanding  of  addiction-disease  in  the  past. 
They  have  been  directed  towards  incidental  and  com- 
plicating manifestations.  They  have  no  more  place  in 
the  treatment  of  the  addict  than  they  have  in  the  treat- 
ment of  any  other  disease  condition.  I  know  of  no  med- 
ication that  can  be  called  ^  specific '  in  the  arrest  of  the 
mechanism  of  narcotic  drug  addiction-disease.  There  is 
no  more  of  a  specific  remedy  for  narcotic  drug  addiction 
than  there  is  for  typhoid  or  pneumonia.  The  wide  ad- 
vertisement of  treatments  based  on  supposed  '  specific ' 
action  of  the  products  of  the  belladonna  and  hyoscyamus 
and  similar  groups  is  unfortunate.  They  have  in  my 
opinion,  no  action  as  curative  agents  in  narcotic  drug 
addiction-disease  which  can  entitle  them  to  consideration 
as  specific  or  special  curative  remedies.  The  drugs  of  this 
group  are  useful  in  many  cases,  intelligently  applied  to 
meet  therapeutic  indications.  They  exhibit  wide  varia- 
tion of  action  and  reaction  in  narcotic  drug  addicts  at 
different  clinical  stages  and  under  different  clinical  con- 
ditions, and  their  dosage  presents  an  extremely  wide  range 
of  individual  measure.  They  are  dangerous  drugs  in  the 
hands  of  the  inexpert  or  careless,  or  used  in  a  routine 
manner  or  dosage.  The  status  which  they  have  acquired 
as  specific  medication  in  narcotic  addiction  disease  I  hold 
to  be  a  medical  fallacy  which  should  be  strongly  opposed 
and  early  remedied." 

The  search  for  panaceas,  specifics  and  routine  treat- 
ments has  constituted  a  stage  in  the  therapeutic  history 
of  most  disease  conditions.  It  marks  the  effort  to  make 
wide  and  general  application  of  a  partial  comprehension 


TREATING  NARCOTIC  DRUG  ADDICTION      57 

of  facts  and  imperfect  recognition  of  fundamentals  and 
is  successful  only  as  an  individual  case  is  occasionally 
capable  of  responding,  perhaps  by  clinical  accident,  to  tbe 
specific  routine  employed. 

Undue  insistence  and  publicity  secured  for  or  given  to 
a  procedure  of  this  description,  is  a  real  obstacle  to  the 
development  of  clinical  and  scientific  understanding  of 
the  condition  treated.  It  distracts  attention  from  broad 
clinical  consideration  of  disease  itself,  from  scientific  in- 
vestigation into  pathology  and  disease  mechanism,  from 
determination  and  observation  of  fundamental  facts, 
whose  comprehension  and  analysis  form  the  essential  fac- 
tor in  the  widespread  successful  handling  of  any  condi- 
tion, and  from  proper  conception  and  appreciation  of  the 
addiction  patient  and  the  addiction  problem  as  a  whole 
with  its  many  and  varied  aspects. 

Various  procedures  in  themselves,  however,  are  not  to 
be  utterly  discredited  and  condemned.  They  have  per- 
formed a  function  in  a  transitional  stage  of  education  and 
progress.  They  can  all  bring  evidence  in  support  of  some 
"  cures."  In  their  origin  and  inception  they  represent 
honest  effort,  study  and  original  thought.  In  analysis  of 
them  can  be  seen,  in  the  minds  of  those  who  first  evolved 
them,  recognition  and  application  of  one  or  another  of 
the  basic  elements,  reactions  or  facts  of  addiction-disease. 
Each  generation  builds  upon  and  adds  to  the  work  of  the 
previous  one,  discards  or  adopts  according  to  its  more 
complete  knowledge.  We  are  building  upon  the  various 
procedures  of  the  past  just  as  our  successors  will  build 
upon  our  work  of  the  present  and  will  discard  or  adopt 
our  v-arious  instruments  and  theories. 

We  are  nearing  the  end  of  consideration  of  routinely 
applied  procedures,  in  all  diseases.  In  addiction  we  are 
entering  upon  a  stage  of  attitude  and  handling  in  which 
there  shall  be  in  each  case  comprehension  of  intrinsic 
elements  and  appreciation   of  their  relative  importance. 


58  THE  NARCOTIC  DRUG  PROBLEM 

and  in  wliicli  there  shall  be  competent  interpretation  of 
symptomatology  and  competent  selection  and  application 
of  therapeutic  measures,  placing  our  efforts  on  a  rational 
basis  and  adapting  handling  and  treatment  to  the  needs 
of  the  individual. 

Our  stumbling-block  in  the  past  has  been  that  our  minds 
have  been  too  much  focused  upon  the  mere  use  of  narcotic 
drug  and  upon  the  stopping  of  drug  use  and  too  little  upon 
the  individual  we  were  treating  and  the  mechanism  of  his 
disease.  We  have  tended  to  apply  our  remedial  efforts  to 
narcotic  use  instead  of  to  narcotic  drug  addiction-disease. 

This  may  explain  the  paucity  of  clinical  and  scientific 
information  as  to  addiction-disease  coming  from  the  in- 
stitutions in  which  these  cases  are  gathered.  It  seems 
to  be  the  fact  that  the  narcotic  wards  of  our  great  charity 
hospitals  and  institutions  of  custody  and  correction  still 
in  gTcat  measure  proceed  with  their  handling  of  narcotic 
addicts  on  the  basis  of  mental  or  moral  degeneracy  or 
deficiency  or  weakness  of  will,  or  morbid  appetite,  etc., 
or  apply  one  or  another  of  the  various  remedies  or  com- 
binations of  remedies.  Their  internes  and  nurses  do  not 
seem  to  graduate  with  a  conception  of  addiction  as  a 
definite  physical  disease,  with  clinically  significant 
symptomatology  and  constant  physical  reactions  and  phe- 
nomena. That  these  institutions  have  after  many  years 
given  us  so  little  information  as  to  the  definite  physical 
symptoms  and  phenomena  which  their  patients  constantly 
manifest  is  in  large  measure  the  result  of  attention  directed 
to  control  of  drug  use  instead  of  to  alleviation  of  physical 
addiction-disease.  There  has  been  much  discussion  over 
various  methods  of  treatment  and  over  measures  for  the 
control  of  patient  and  of  narcotic  drug,  and  there  has  been 
insufficient  study  and  analysis  of  the  clinical  details  of 
addiction-disease  manifestations  and  their  possible  thera- 
peutic significance. 

There  has  been  of  late,  however,  signs  of  change  in 


TREATING  NARCOTIC  DRUG  ADDICTION      59 

this  situation,  and  in  this  change  lies  one  of  the  greatest 
hopes  of  solution  of  the  narcotic  drug  prohlcm.  The  at- 
titude towards  addiction  is  heginning  to  follow  th©  trend 
of  modern  medicine  in  getting  away  from  special  or 
routine  treatments,  and  the  search  for  specifics  and  pan- 
aceas, and  in  aiming  at  and  devoting  great  effort  to  the 
searching  out,  consideration  of,  and  treatment  of  funda- 
mental cause  and  underlying  condition.  When  this 
method  of  approach  is  applied  widely  to  addiction-dis- 
ease, and  the  facilities  of  our  great  hospitals  and  institu- 
tions of  research  properly  directed  to  its  furtherance, 
there  will  come  a  re-arrangement  of  conception  of  opiate 
addiction.  Restraint  and  custodial  care,  and  psychologic 
and  psychiatric  classification  will  be  applied  more  spar^ 
ingly.  Many  worthy  sick  people  will  —  instead  of  being 
refused  treatment,  or  turned  back  upon  their  own  re- 
sources after  inadequate  treatment  —  thus  adding  to  the 
public  and  private  burden  of  the  care  of  the  unfit  —  be 
rationally  treated  as  sick  people  and  returned  to  health 
and  self-supporting  competency. 

The  one  great  point  to  be  kept  in  mind  is  that  narcotic 
addicts  are  sick;  sick  of  a  definite  and  now  demonstrable 
disease.  This  disease  is  variously  complicated  and  widely 
variable  as  it  occurs  in  individual  patients.  Although 
some  individuals,  afflicted  with  this  disease,  may  require 
custodial  or  correctional  handling  —  the  fundamental 
physical  disease  cannot  be  properly  arrested  nor  handled 
successfully  by  mental,  moral,  sociological  or  penological 
methods  only.  Any  toxic,  worried,  fear-ridden  or  suf- 
fering sick  man  may  show  psychological  or  even  psychia- 
trical manifestations  or  complications,  but  observing  and 
attempting  to  control  complications  only  will  not  cure 
basic  disease. 

Even  if  it  should  some  day  develop  that  a  serum  can 
be  produced  against  the  underlying  toxins  of  addiction- 
disease  ;  and  this  is  not  beyond  the  bounds  of  possibility ; 


60    THE  NARCOTIC  DRUG  PROBLEM 

its  usefulness  and  application  must  remain  for  the  pres- 
ent matter*  of  academic  speculation.  Other  than  this 
possibilitj,  there  seems  practically  no  hope  of  a  properly 
called  "  specific  medication  "  in  narcotic  drug  addiction^ 
disease.  Even  with  its  discovery,  it  is  highly  improbable 
that  a  routine  treatment  applicable  to  all  cases  could  ever 
be  successfully  adopted.  In  the  very  few  disease  condi- 
tions in  which  we  can  properly  be  said  to  have  "  specific '' 
medication,  routine  handling  and  treatment  of  all  cases 
is  inadvisable  and  unsatisfactory. 

There  is  not  and  probably  never  will  be  any  specific 
routine  treatment  successfully  applicable  to  all  cases  of 
any  complex  and  variable  disease  condition.  We  shall 
save  much  public  money,  and  personal  effort  and  time, 
and  shall  save  the  narcotic  addict  much  suffering  and  dis- 
couragement, and  shall  add  much  to  human  health,  com- 
petency and  happiness  when  we  realize  these  facts  as  ap- 
plied to  addiction-disease,  and  proceed  upon  them  in  a 
spirit  of  broad  humanity  and  of  rational  clinical  study  and 
remedy  of  obvious  disease  symptomatology.  Narcotic 
drug  addiction-disease  is  a  definite,  and  in  most  cases 
arrestable  disease.  It  should  be  widely  so  regarded  and 
studied  and  treated. 


CHAPTER  VI 

THE  EATIONAL    HAI^DLING   OF   NAECOTIC   DEUG 
ADDICTION-DISEASE 

If  anything  has  been  demonstrated  conclusively  con- 
cerning narcotics  it  is  that  the  methods  of  the  past,  legal, 
administrative,  and  medical,  have  not  solved  the  narcotic 
drug  problem,  nor  controlled  the  narcotic  drug  situation, 
nor  been  successful  in  the  handling  of  the  narcotic  drug 
addict. 

Some  factor  or  element  of  great  and  fundamental  im- 
portance has  obviously  been  neglected.  This  lacking 
element  is  general  recognition  of  the  presence  of  disease 
processes  which  cause  the  symptomatology  and  phenomena 
of  body-need  for  opiate  drug.  One  of  the  essentials  for 
the  practical  solution  and  management  of  the  narcotic  drug 
problem  is  the  realization  by  the  medical  profession, 
legislators,  administrators  and  laity  that  opiate  drug  ad- 
diction is  a  definite  disease  entity,  to  be  treated  as  such, 
and  calling  for  extensive  clinical  and  laboratory  investi- 
gation and  study  such  as  have  been  accorded  other  dis- 
eases over  which  we  have  gained  the  mastery.  One  of 
the  most  needed  achievements  in  the  line  of  practical 
remedy  is  the  admission  of  narcotic  drug  addiction-dis- 
ease to  its  legitimate  place  as  an  accepted  part  of  the  prac- 
tice of  internal  medicine  and  the  stimulating  of  education  '\ 
concerning  it  "among  medical  practitioners,  medical  stu- ^ 
dents  and  nurses. 

As  was  stated  in  the  last  chapter,  too  much  emphasis 

has  been  placed  on  drug  use  and  drug  withdrawal,  as  if 

the  drug  itself  were  the  most  important  element  in  the 

clinical  picture  of  addiction.     In  the  handling  and  treat- 

61 


62  THE  NARCOTIC  DRUG  PROBLEM 

ment  of  addiction-disease  it  should  be  constantly  borne  in 
mind  that  the  ultimate  withdrawal  of  opiate  from  the 
addict  is  simply  one  stage,  and  not  by  any  means  the 
most  important  consideration  in  his  rational  handling. 
Its  management  in  most  cases  is  a  matter  of  scientific 
clinical  certainty  and  satisfactory  accomplishment  by  the 
physician  who  understands  the  disease  he  is  treating  and 
who  is  clinically  proficient  in  the  control  of  its  elements 
by  indicated  therapeutic  procedure.  The  ease  of  hand- 
ling the  stage  of  final  withdrawal,  the  extent  to  which 
suffering,  nervous  strain  and  exhaustion  can  be  avoided 
in  it,  and  its  final  issue  depend  greatly  upon  the  physical 
and  reactive  condition  of  the  man  from  whom  drug  is 
withdrawn.  Like  the  stage  of  crisis  in  pneumonia,  its 
course  and  conduct  and  results  are  largely  influenced  by 
the  condition  in  which  the  patient  approaches  the  with- 
drawal. It  is  of  vastly  more  importance  to  measure  and 
control  reactions  and  treat  a  patient  so  as  to  get  him  into 
the  fittest  possible  condition  for  final  withdrawal  and 
rapid  convalescence,  than  it  is  to  focus  attention  on  the 
mere  reduction  or  withdrawal  of  drug,  or  on  the  mere 
amount  of  drug  used.  Linal  withdrawal  of  drug,  like  an 
operation  of  election,  is  to  be  done  when  the  patient  is  in 
the  fittest  condition  and  ready  for  it.  With  the  addict 
who  is  well  nourished,  non-inhibited,  and  physically  and 
glandularis^  reactive,  it  can  be  accomplished  with  little 
or  no  discomfort,  in  a  very  short  time,  leaving  practically 
nothing  to  demand  a  protracted  and  difficult  stage  of  con- 
valescence or  of  so-called  ^'  after  care.'* 

It  becomes  evident,  therefore,  that  the  handling  of  an 
opiate  addict,  preliminary  to  withdrawal  of  the  drug  to 
which  he  is  addicted  is  of  greatest  importance.  The  ease 
of  withdrawal  and  rapidity  and  completeness  of  subse- 
quent recuperation,  is  largely  commensurate  with  the  ex- 
tent of  organic  dependence  upon  the  drug  and  the  physical 
condition  of  the  patient.     One  man  using  the  same  amount 


NARCOTIC  DRUG  ADDICTION-DISEASE     63 

as  another  is  dependent  upon  its  effects  for  the  support 
of  his  organic  processes  to  a  much  greater  extent.  The 
evident  solution  lies  in  a  preliminary  stage,  removing  in- 
hibition, reducing  in  so  far  as  possible  organic  and  func- 
tional dependence  upon  drug,  and  putting  the  patient  into 
the  best  possible  reactive  condition.  I  believe  that  in 
many  cases  it  is  imperative  for  successful  issue  to  train 
the  patient  for  the  shock  and  strain  of  opiate  withdrav^al 
and  in  practically  all  other  cases,  though  less  imperative, 
most  desirable. 

It  has  been  objected  that  this  v\;^ill  prolong  treatment. 
My  experience  has  been  that  it  very  much  facilitates  with- 
drawal treatment,  and  not  only  renders  it  easier  and  more 
uniformly  successful  and  complete,  but  that  it  tends  to 
shorten  and  make  less  troublesome,  and  in  some  cases 
practically  eliminates,  convalescence. 

I  have  therefore  instituted  as  an  important  part  of  my 
procedure,  a  Preliminary  Stage  of  study  and  handling 
and  treatment  of  my  patient  before  attempting  withdrawal 
of  the  drug.  During  this  time  I  study  my  patient,  re- 
garding him  not  simply  as  a  narcotic  addict  but  as  a 
sick  man  to  be  investigated  as  carefully  as  a  cardiac  or 
any  other  patient,  and  all  his  organic  and  functional 
conditions  appreciated,  and  all  of  his  functional  and 
glandular  actions  estimated  in  their  competency  and  bal- 
ance and  their  reactions  both  to  the  drug  of  addiction  and 
to  the  influences  of  addiction  disease  mechanism.  Condi- 
tions long  masked  by  opiates,  and  forgotten,  even  by  the 
patient  himself,  may  seriously  affect  treatment,  con- 
valescence and  prognosis  if  undetected  before  withdrawal 
is  instituted.  Their  relations  to  and  possible  influence 
upon  addiction  and  its  treatment,  and  fully  as  important 
—  the  possible  effect  of  treatment  and  withdrawal  of  drug 
upon  them,  should  be  very  carefully  estimated.  If  ad- 
visable or  possible  they  should  be  remedied  before  with- 
drawal of  the  drug  of  addiction. 


64    THE  NARCOTIC  DRUG  PROBLEM 

Also  such  mental  or  psychical  disturbances  as  may  exist 
in  a  given  case  should  be  traced  to  their  origin,  esti- 
mated and  reckoned  with.  Very  often  they  will  be  found 
to  be  not  inherent  but  a  result  of  past  suffering  and 
present  worry  and  fear.  The  patient's  confidence  in  his 
physician's  ability  to  treat  the  disease  from  which  he 
suffers  should  be  strengthened,  and  his  doubts  and  fears 
allayed.  Addiction  patients  are  well  informed  concern- 
ing opiates  and  are  acquainted  with  the  manifestations  of 
addiction-disease,  and  have  had  experience  with  or  full 
information  concerning  the  various  methods  of  cure. 
They  are,  like  any  other  chronic  sick  person,  suspiciously 
and  keenly  analytic  of  themselves  and  of  the  physician, 
and  unless  handled  with  appreciation  of  their  condition 
are  naturally  the  prey  of  constant  worry  and  fear.  Co- 
operation and  confidence  between  patient  and  physician 
vastly  influence  the  amount  of  nervous  energy  expended 
by  both,  and  in  this,  as  in  other  diseases  are  big  factors  in 
treatment  and  in  convalescence. 

Another  advantage  of  a  preliminary  stage  is  one  which 
has  been  too  little  considered,  but  which  will  before  long 
come  to  demand  the  same  intelligent  attention  and  meas- 
ure as  is  given  to  the  contemplation  of  operations  in  and 
treatment  for  chronic  other  conditions.  It  is  this  —  in 
what  condition  will  withdrawal  of  opiate  even  though 
skillfully  conducted  and  successfully  accomplished,  leave 
the  individual  in  his  value  to  himself,  and  to  his  family 
and  to  the  community,  in  view  of  co-existing  physical 
conditions?  Withdrawal  of  opiate  drug  has  been  in  not 
a  few  cases  the  cause  of  transforming  of  a  capable  and 
useful  citizen  into  an  invalid  incompetent,  for  whose  ulti- 
mate salvation  and  competent  physical  and  mental  func- 
tion and  organic  and  glandular  control  resumption  of 
opiate  medication  was  determined  to  be  a  therapeutic 
necessity. 

Such  considerations  as  this  should  be  all  taken,  analyzed 


NARCOTIC  DRUG  ADDICTION-DISEASE     65 

and  estimated  in  a  preliminary  stage  and  if  treatment 
is  only  going  to  injure  a  patient  lie  slionld  be  instructed 
how  to  handle  his  addiction,  and  advised  to  continue  his 
opiate  medication^  and  not  be  subjected  to  useless  expense 
and  trials. 

Basic  Principles  of  Addictiorirdisease  Handling 

Intelligent  addicts  well  know  that,  other  factors  being 
equal,  the  less  number  of  times  in  a  day  they  take  their 
drug,  the  less  inhibited,  the  less  constipated  and  more  nor- 
mal they  are,  and  the  smaller  amount  of  narcotic  drug  they 
require  to  maintain  them  physically  and  mentally  com- 
petent. It  is  unfortunate  that  this  therapeutic  principle 
so  widely  recognized  among  intelligent  addicts  has  not  re- 
ceived full  recognition  and  therapeutic  employment  by  all 
of  those  who  handle  and  treat  addiction-disease.  Its  prob- 
able explanation  is  very  simple  —  apparently  a  period  of 
inhibition  follows  the  administration  of  narcotic  or  opiate 
drugs ;  and  the  length  of  this  period  is  not  in  ratio  to  the 
size  of  the  dose  administered.  Consequently,  the  fewer 
number  of  times  in  a  day  a  dose  of  narcotic  drug  is  ad- 
ministered, the  greater  amount  of  competent  metabolism 
is  present  —  the  more  adequate  is  the  patient's  elimination 
and  nutrition  —  the  smaller  amount  of  opiate  or  its 
product  lies  stored  in  inhibited  and  atonic  cells,  and  the 
smaller  amount  of  antidotal  substance  is  manufactured 
for  the  protection  of  the  body,  and  to  some  extent,  the 
smaller  amount  of  opiate  is  required. 

In  caring  for  the  narcotic  addict,  therefore,  one  of  the 
most  important  therapeutic  measures  is  the  regulation  of 
the  interval  of  his  narcotic  drug  administration.  I  have 
repeatedly  experimented  upon  addicts  who  were  not  con- 
fined or  under  restraint  in  any  way.  I  explained  to  them 
the  inhibitory  effects  of  too  frequent  dosage  and  instructed 
them  to  use  the  amount  of  drug  they  found  necessary  for 
twenty-four   hours   in   larger   doses    at   longer    intervals. 


66  THE  NARCOTIC  DRUG  PROBLEM 

This  procedure  alone,  in  many  cases  transforms  the  pallid, 
starved,  constipated  and  deteriorated  addict  within  a  sur- 
prisingly short  time  into  a  well-nourished,  well-reactive 
and  practically  normally  functionating  individual.  With 
the  return  of  health,  vitality,  and  normal  nutrition  and 
elimination,  his  hody  requires  still  less  drug  and  he  vol- 
untarily and  without  mental  struggle  and  nervous  strain 
reduces  the  amount  of  drug  used.  I  wish  to  emphasize 
that  in  these  experimental  cases  there  were  no  other 
therapeutic  measures  employed  in  the  way  of  medication. 

The  practical  therapeutic  application  of  wide-interval 
administration  of  opiate  drug  is  made  possible  by  the 
fact  that  the  narcotic  addict  can  tolerate  without  harm 
large  doses  of  the  drug  of  addiction.  It  is  made  con- 
trollable by  the  fact,  that,  within  certain  limits,  the  length 
of  time  over  which  a  dose  of  narcotic  drug  will  maintain 
a  patient  in  narcotic  drug  balance  —  or  free  from  the 
symptomatology  of  drug  need  —  is  in  mathematical  ratio 
to  the  size  of  the  dose  administered.  Each  addict  requires, 
under  the  conditions  of  his  daily  life  at  a  given  time,  to 
satisfy  the  demands  of  his  physical  addiction-disease 
mechanism,  and  to  maintain  him  in  narcotic  drug  balance, 
an  amount  of  drug  which  can  be  estimated  in  terms  of 
twenty-four  hours  and  which  I  have  called  the  amount 
of  minimum  daily  need.  The  most  important  considera- 
ation  in  the  administration  of  narcotic  drug  to  a  narcotic 
addict  is  to  supply  the  amount  of  minimum  daily  need 
and  maintain  narcotic  drug  balance  with  the  least  in- 
hibition of  function. 

Failure  to  maintain  narcotic  drug  balance  and  a  de- 
gree below  the  amount  of  minimum  daily  need  renders 
the  addict  functionally  and  physically  incompetent.  He 
is  in  a  condition  of  physical  and  nerve  incapacity  and  ex- 
haustion. He  has  no  physical  tone ;  he  has  markedly  im- 
paired circulation ;  he  cannot  react,  he  has  no  recuperative 
powers;  he  has  constantly  in  his  body,  according  to  mod- 


NARCOTIC  DRUG  ADDICTION-DISEASE     67 

ern  theory,  unneutralized  autogenous  poison  wliicli  robs 
him  of  vitality,  reaction  and  functional  efficiency  even 
though  it  may  not  be  present  in  sufficient  amounts  to  give 
rise  to  the  violent  spectacular  and  agonizing  manifesta- 
tions of  complete  narcotic  deprivation.  In  other  words, 
as  I  have  written  elsewhere,  "  the  reduction  of  the  drug 
of  addiction  below  the  amount  of  body-need  robs  the 
addict  of  his  most  valuable  asset  in  securing  and  main- 
taining recuperative  powers."  In  no  other  disease  would 
an  intelligent  physician  persist  in  the  application  of  meas- 
ures which  robbed  his  patient  of  recuperative  powers  and 
expect  satisfactory  issue  of  the  case  he  was  trying  to 
treat.  Until  the  physician  and  patient  are  ready  and  pre- 
pared for  the  institution  of  the  stage  of  final  withdrawal 
of  drug,  the  patient  should  never  be  allowed  to  drop  be- 
low the  amount  of  minimum  daily  need  in  his  opiate 
intake. 

It  is  evident  therefore,  that  upon  the  intelligent  and 
competent  estimation,  measure  and  control  of  physical 
narcotic  drug  balance  and  inhibition  of  function  depend 
the  reaction,  well  being  and  therapeutic  progress  of  the 
man  who  has  narcotic  drug  addiction-disease.  These  fac- 
tors also  markedly  influence  the  action  of  all  medication, 
including  the  drug  of  addiction,  upon  the  body  of  the 
opiate  addict.  They  influence  the  reaction  of  the  addict's 
body  to  all  medication.  Medication  cannot  be  intelli- 
gently administered  to  the  opiate  addict  unless  those  who 
administer  it  have  understanding  and  clinical  appreciation 
of  the  widely  varying  reaction  of  the  addict  under  differ- 
ent conditions  of  drug  balance  and  inhibition  of  function. 
Failure  to  recognize  and  appreciate  this  fact  explains  a 
considerable  portion  of  the  past  failures  and  the  past 
mortality  attending  specific  and  special  methods  and 
treatments,  and  so-called  ^^  cures."  The  dosage  of  medica- 
tion administered  and  the  time  of  its  administration 
should  therefore  be  determined  upon  with  watchful  eye  to 


68     THE  NARCOTIC  DRUG  PROBLEM 

the  reaction  of  the  patient,  and  with  intelligent  compre- 
hension of  the  possibilities  in  reactionary  change. 

The  actions  and  the  dosage  of  therapeutic  agents  have 
been  largely  determined  by  experimentation  on  individ- 
uals and  animals  of  average  normal  reaction.  The  toxic, 
the  inhibited  and  the  narcotic  addicted  do  not  display 
the  normal  reaction  to  therapeutic  agents.  Under  some 
conditions  they  over-react  both  physically  and  nervously, 
and  under  other  conditions  they  under-react.  Detailed 
consideration  of  this  matter  is  not  possible  in  this  book. 
It  offers  for  investigation  a  field  well  worthy  of  exploration 
both  clinical  and  laboratory.  It  will  only  state  that  as 
the  manifestations  and  influences  of  toxemia,  functional 
exhaustion,  inhibition,  and,  in  the  addicted,  of  varying 
physical  diTig  balance,  have  become  increasingly  definite 
and  tangible  and  capable  of  clinical  measure  and  determin- 
ation, my  medication  of  the  toxic  and  the  exhausted  and 
the  inhibited  individual,  as  well  as  of  the  narcotic  ad- 
dicted, has  become  progressively  more  effective.  These  ob- 
servations apply  to  conditions  other  than  opiate  drug  ad- 
diction, and  are  worthy  of  consideration  in  all  toxic,  and 
exhaustion  and  depression  states. 

I  have  already  spoken  of  the  imperative  physical  need 
for  the  drug  of  addiction.  I  have  also  referred  to  the 
amount  of  minimum  daily  need  for  the  drug  of  addiction. 
The  recognition  of  factors  which  influence  these  is  of  great 
importance.  Many  of  these  factors  are  so  commonplace 
and  so  obvious  in  their  relation  to  the  extent  of  body  need 
that  they  are  appreciated  by  most  intelligent  addicts. 
Anything  which  increases  the  expenditure  of  physical  and 
nervous  energy  increases  the  addict's  need  for  opiate  drug. 
iVmong  the  most  potent  influences  are  worry,  fear  and 
physical  suffering.  They  consume  physical  fuel;  and  an 
important  part  of  the  addict's  physical  fuel  is  the  drug  of 
his  addiction.  In  addition  to  this,  worry  and  fear  and 
suffering  are  also  markedly  inhibitory  of  glandular  and 


NARCOTIC  DRUG  ADDICTION-DISEASE     69 

peristaltic  function.  The  expenditure  of  energy  in  mental 
and  muscular  work  also  calls  for  increased  supply  of  tlie 
drug  of  addiction.  I  need  not  enlarge  upon  this  impor- 
tant fact.  Its  application  to  the  handling  and  treatment 
of  the  addict  is  evident.  Narcotic  drug  should  be  supplied 
to  meet  the  physical  needs  of  the  individual  case,  and  only 
be  decreased  as  intelligent  handling  of  the  factors  which 
determine  that  need  have  lessened  it. 

The  method  of  gradual  reduction  of  dose  to  the  point  ^ 
of  ultimate  discontinuance  is  practical  and  feasible  imder 
conditions  and  at  an  expense  of  time  and  money  which  are 
possible  to  but  very  few  addicts.  The  forcible  reduction 
of  dose  without  regard  to  the  environmental,  mental,  eco- 
nomic, physical  or  other  conditions  of  the  average  and  in- 
dividual addict,  and  absolutely  ignoring  the  considerations 
of  the  mechanism  and  symptomatology  of  his  addiction- 
disease  is  barbarous,  harmful  and  futile.  Enforced  re- 
duction of  dose  below  the  point  of  body  need  is  not  worth 
what  it  costs  in  nerve-strain,  suffering,  and  physical  in- 
adequacy. The  extent  of  addiction-disease  and  the  de- 
gree of  progress  in  its  remedy  cannot  be  measured  in 
terms  of  amount  of  drug  administered.  It  must  be  meas- ) 
ured  in  terms  of  clinical  symptomatology,  just  as  progress 
is  measured  in  any  other  disease.  Reduction  of  dose  be- 
low the  amount  of  body  need,  prior  to  the  stage  of  final 
withdrawal,  constitutes  a  serious  therapeutic  handicap 
and  is  most  decidedly  contra-indicated.  Withdrawal  of 
opiate  from  an  addict  whose  physical  reaction  and  strength 
and  nerve  force  have  been  reduced  and  depleted  by  con- 
tinued reduction  of  amount  of  drug  without  commensur- 
ate reduction  in  the  extent  of  body  need  is  harder  than 
withdrawal  from  a  reactive  individual  with  reserve  nerve 
and  physical  force  who  may  be  taking  a  much  larger  dose. 

The  average  addict  must  support  himself  and  his  family. 
His  physical  well-being  and  economic  efficiency  should  be 
considerations  in  the  welfare  of  the  community  in  which 


70     THE  NARCOTIC  DRUG  PROBLEM 

he  lives.  Legislative  and  other  investigation  has  shown 
that  we  are  entirely  unequipped  both  institutionally  and 
professionally  for  the  successful  immediate  withdrawal  of 
opiate  from  even  a  small  proportion  of  our  present  census 
of  the  opiate  addicted.  In  view  therefore,  of  the  practical 
impossibility  of  immediate  successful  withdrawal  treat- 
ment, and  in  view  of  what  is  known  and  can  be  demon- 
strated and  taught  in  the  accomplishment  of  final  with- 
drawal, I  do  not  hesitate  to  state  that,  until  we  are  pre- 
pared and  in  a  position  to  skillfully  and  competently 
handle  the  stage  of  final  withdrawal  to  assured  successful 
issne,  it  is  much  wiser  to  supply  to  the  addict  who  is  not 
a  public  menace  the  drug  of  his  addiction  to  the  extent  of 
his  physical  needs,  and  to  teach  him  how  to  use  the  drug 
of  addiction  in  such  a  way  as  will  maintain  his  physical 
and  economic  efficiency,  than  it  is  by  enforced  reduction 
of  dose  to  deprive  him  for  a  long  time  of  working  ability 
and  his  family  of  his  support.  Furthermore,  the  addict 
who  is  insufficiently  supplied  with  the  opiate  of  his  addic- 
tion, turns  in  desperation  to  the  use  of  things  far  more 
harmful  to  him  than  the  drug  of  his  addiction.  This  he 
does  in  the  vain  hope  of  obtaining  mental  and  nervous 
and  physical  stimulus  and  support  and  some  surcease  of 
his  misery.  The  many  wrecks  of  addicts  to  be  seen  try- 
ing through  insufficient  supply  of  narcotic  drug,  self- 
poisoned  with  other  drugs  which  they  have  purchased, 
alcohol,  bromides,  coal  tar  products,  cocaine,  and  of  late 
hyoscine  —  their  addiction  disease  unrelieved  and  un- 
diminished —  are  sufficient  argument  against  mere  re- 
duction of  dose,  below  physical  body  need. 

The  personal  attitude  of  the  physician  towards  opiate 
addicted  patients  is  of  great  importance.  The  medical 
man  who  is  to  treat  a  case  suffering  from  addiction-dis- 
ease successfully  to  the  end  of  relieving  this  condition,  or 
who  is  treating  addiction-disease  as  an  intercurrent  con- 
dition complicating  another  disease,  must  first  of  all  make 


NARCOTIC  DRUG  ADDICTION-DISEASE     71 

his  patient  realize  tliat  the  physician  himself  knows  some- 
thing about  addiction  as  a  disease.  He  must  never  give 
his  patient  any  hint  or  reason  to  suspect  that  he  regards 
opiate  addiction  as  a  habit,  a  vice,  a  degrading  indulgence 
which  can  be  to  any  curative  or  even  therapeutic  extent, 
combatted  by  the  exercise  of  will-power. 

In  their  desperation  and  ignorance,  the  vast  majority 
of  addicts  have  repeatedly  exercised  will-power  in  self- 
denial  of  their  drug  to  the  limits  of  their  physical  en- 
durance, and  they  know  the  futility  and  suffering  of  at- 
tempts based  simply  and  solely  upon  the  exercise  of  will- 
power. Experience  has  taught  them  actual  facts  concern- 
ing the  physical  action  of  narcotic  drugs  and  concerning 
the  results  of  insufficient  supply  of  narcotic  drug  in  a  man 
who  is  addicted.  The  addict  knows  that  he  does  not  take 
a  drug  because  he  enjoys  it.  He  knows  that  he  exper- 
iences no  sensuous  gratification  or  other  pleasure  from  its 
administration.  He  knows  that  he  uses  a  narcotic  drug 
simply  and  solely  because  he  has  to  use  it  to  escape  physical 
incompetence  and  physical  agony.  As  I  said  before,  al- 
most without  exception  the  narcotic  addict  has  proceeded 
of  his  own  accord,  or  under  the  direction  and  advice  of 
others,  on  the  theory  of  exercising  will  power,  and  resist- 
ing temptation.  With  the  few  exceptions  of  those  made 
in  a  very  early  stage  and  before  addiction  mechanism  had 
become  strongly  developed  and  rooted  in  his  physical 
processes,  such  efforts  on  the  basis  of  this  theory  have 
been  useless. 

It  is  practically  impossible  to  argue  successfully  on  the 
basis  of  theory  with  the  man  who  has  experienced  facts. 
Narcotic  addiction  furnishes  a  class  of  patients  who  know 
more  about  their  own  disease  than  any  other  class  of 
people.  They  can  accurately  estimate  the  extent  of  un- 
derstanding and  knowledge  possessed  by  the  man  who  is 
treating  them,  and  they  are  desperately  critical.  Almost 
without  exception,  except  for  some  of  the  true  ''  under- 


72     THE  NARCOTIC  DRUG  PROBLEM 

world/^  they  desire  above  all  else  to  escape  from  their 
v^  condition.  I  know  tbat  this  is  not  tbe  popular  conception 
and  for  the  present  may  be  by  some  regarded  as  heresy. 
Therefore,  it  is  of  essential  importance  that  between  the 
doctor  who  treats  an  addict  of  average  intelligence  and 
that  addict  must  exist  co-operation  and  understanding. 
As  soon  as  this  patient  realizes  two  things  —  that  the 
doctor  does  not  believe  his  expressed  wish  to  be  cured,  and 
that  he  interprets  the  patient's  desire  for  relief  from 
suffering  as  simply  a  desire  for  more  opiate  and  the  ex- 
pression of  habit,  vice  or  degraded  appetite  which  should 
be  controlled  by  the  exercise  of  ''  will-power,"  —  there  is 
an  end  to  that  patient's  confidence  in  that  doctor,  and  to 
the  help  that  that  doctor  can  give  to  that  patient.  As  I 
have  written  elsewhere,  the  opiate  addict  of  average  in- 
telligence will  co-operate  with  his  medical  adviser  to  the 
extent  of  his  physical  endurance,  so  long  as  he  has  any 
belief  in  that  adviser's  understanding  of  his  condition, 
and  ability  to  help  him. 

In  my  own  work,  and  as  a  result  of  my  own  experience 
I  have  found  that  as  a  rule  the  extent  to  which  an  in- 
telligent addiction  patient  cooperates  with  me  has  been  a 
measure  of  the  understanding  and  technical  ability  with 
which  I  handled  him,  rather  than  a  measure  of  his  de- 
sire to  be  helped.  It  is  held  by  many  that  a  majority  of 
addiction-patients  are  not  possessed  of  average  intelligence 
and  are  not  honest  in  their  statements.  I  will  simply  say 
that  even  in  the  Alcoholic  and  Prison  Wards  of  Bellevue 
and  in  the  narcotic  wards  of  the  ISTew  York  Workhouse 
Hospital  I  came  more  and  more  to  seek  in  faults  of  medical 
and  nursing  handling  the  explanation  of  apparent  lack  of 
cooperation.  In  the  Annual  Report  of  the  ^Tew  York  De- 
partment of  Correction  for  1915,  in  commenting  upon  the 
work  of  the  narcotic  wards,  is  stated,  "  In  ratio  as  there 
has  been  at  any  given  time  among  our  interne  and  nursing 
staff  comprehension  and  understanding  of  the  manifesta- 


NARCOTIC  DRUG  ADDICTION-DISEASE     73 

tions  and  underlying  principles  of  narcotic  drug  addiction- 
disease  and  of  its  rational  handling  in  the  individual 
case,  our  results  have  been  good  or  bad." 

Several  years  ago  I  wrote  as  follows :  ^^  As  to  the  ex- 
isting opinion  that  the  morphinist  does  not  want  to  be 
cured  and  that  while  under  treatment  he  cannot  be  trusted 
and  will  not  cooperate  but  will  secretly  secure  and  use  his 
drug,  I  can  only  quote  from  personal  experience  with  these 
cases.  During  my  early  attempts,  my  patients,  beginning 
with  the  best  intentions  in  the  world,  often  tried  to  beg, 
steal  or  get  in  any  possible  way,  the  drug  of  their  addic- 
tion. Like  others  I  placed  the  blame  upon  their  sup- 
posed weakness  of  will  and  lack  of  determination  to  get 
rid  of  their  malady.  Later  I  realized  the  fact  that  the 
blame  rested  entirely  upon  the  shoulders  of  my  medical 
inefficiency  and  my  lack  of  understanding  and  ability  to 
observe  and  interpret  my  patient's  condition.  The  mor- 
phinist as  a  rule  will  cooperate  and  will  suffer  to  the  limit 
of  his  endurance.  Demanding  cooperation  of  a  case  of 
morphinism  during  and  following  incompetent  with- 
drawal of  the  drug  is  much  like  asking  a  man  to  cooper- 
ate for  an  indefinite  period  in  his  own  torture.  There  is 
a  limit  to  every  one's  power  of  endurance  of  suffering." 

Of  primary  importance,  then,  if  a  physician,  institu- 
tional or  practitioner,  is  to  have  any  success  in  handling 
a  case  of  opiate  addiction-disease,  is  his  attitude  towards 
his  patient  —  divesting  himself  of  all  conception  of  habit, 
appetite  or  vice  as  explanation  of  characteristic  physical 
manifestations  and  symptomatology,  and  approaching  the 
patient  as  a  man  with  a  definite  disease  requiring  and  de- 
serving intelligent  clinical  handling.  The  patient  will  be 
the  very  first  to  mark  a  physician's  shortcomings.  If  he 
has  not  confidence  in  the  doctor's  ability  and  understand- 
ing of  his  illness  the  doctor  can  help  him  but  little.  This 
statement  applies  not  to  addiction-disease  alone  but  to 
every  medical  condition. 


74     THE  NARCOTIC  DRUG  PROBLEM 

There  are  three  clinical  demonstrable  elements  to  be 
determined,  measured  and  controlled  in  the  actual 
therapeutic  handling  of  cases  of  narcotic  addiction-disease. 
The  first  of  these  is  the  actual  amount  of  drug  which  the 
patient's  body  demands  to  maintain  functional  and  or- 
ganic efficiency  and  to  escape  physical  distress.  The  sec- 
ond of  these  is  the  extent  of  auto-  and  intestinal-intoxica- 
tion, autotoxicosis  and  malnutrition.  The  third  of  these, 
which  is  both  a  result  of  and  a  causative  element  in  the 
other  two,  is  the  extent  of  inhibition  of  function. 

In  the  successful  handling  of  a  case  of  addiction-dis- 
ease, therefore,  the  first  effort  should  be  to  determine  ap- 
proximately the  amount  of  the  patient's  minimum  daily 
physical  need  for  the  drug  of  his  addiction.  This  need 
is  clinically  recognizable  and  definitely  measurable.  It 
should  be  met  to  whatever  extent  it  is  present  so  long  as  it 
exists,  and  dosage  diminished  only  as  competent  treatment 
diminishes  the  extent  of  need.  This  physical  need  can 
be  demonstrated  and  accurately  measured  by  clean-cut 
symptomatology.  It  can  be  expressed  in  mathematical 
terms  of  amounts  of  drug  required  in  twenty-four  hours. 
Work,  worry,  strain  —  anything  which  consumes  physical 
or  nervous  energy  increases  this  need.  If  this  physical 
need  is  not  met  the  patient  is  robbed  of  physical  tone  and 
physical  reaction.  He  is  robbed  of  metabolic  balance  and 
functional  competency.  He  is,  in  short,  robbed  of  the 
basic  ability  which  his  body  has  to  regain  health. 

In  the  estimation  of  this  amount  of  physical  need  the 
procedure  is  very  simple.  Have  administered  to  the 
patient  who  is  manifesting  the  symptomatology  of  drug- 
need,  sufficient  drug  to  remove  the  symptoms  and  restore 
him  to  complete  physical,  functional  and  nerve  balance. 
Have  the  length  of  time  observed  which  elapses  before 
the  symptoms  of  drug  need  reappear.  Have  this  repeated 
several  times  and  information  is  secured  as  to  what  quant- 
ity of  opiate  under  the  existing  conditions  will  hold  that 


NARCOTIC  DRUG  ADDICTION-DISEASE     75 

patient  in  drug-balance  for  a  known  length,  of  time.  In 
this  way  can  be  matbematicallj  estimated  the  extent  of 
physical  drug-need.  The  average  need  for  twenty-four 
hours  can  be  easily  computed  from  the  data  obtained. 
It  is  merely  a  matter  of  arithmetic. 

The  regulation  of  dosage  can  also  be  estimated  with 
approximate  accuracy.  As  has  been  stated  before,  the 
interval  of  freedom  from  withdrawal  manifestations  is 
found  to  be,  in  a  general  way  and  within  certain  limits, 
in  ratio  to  the  size  of  the  dosage.  Tor  example,  if  in  a 
given  case,  under  given  conditions  of  fear,  worry,  physical 
or  nervous  strain,  pain,  etc.,  as  discussed  elsewhere  —  one 
grain  of  morphine  will  last  a  given  patient  at  a  given 
time  for  four  hours ;  under  the  same  conditions  two  grains 
will  last  for  approximately  eight  hours.  There  are  limits 
to  the  application  of  this  rule.  It  is  stated  as  the  general 
operating  of  an  addiction-disease  phenomenon  which,  is 
useful  as  a  therapeutic  guide. 

The  amount  of  actual  physical  body  need  as  capable 
of  approximate  estimation  in  the  above  manner  should  be 
administered  to  the  patient,  any  reduction  being  guided 
by  the  fact  that  his  clinical  symptomatology  and  physical 
manifestations  demonstrate  that  the  amount  required  by 
his  addiction-disease  has  been  reduced.  It  is  much  wiser 
for  the  progress  of  the  average  addiction  case  to  have  the 
drug  administered  in  the  amount  of  estimated  physical 
need  than  it  is  to  attempt  to  reduce  the  amount  of  drug 
before  his  reactions  show  reduction  in  physical  drug-need. 
The  success  of  outcome  and  the  measure  of  progress  in 
such  a  case  is  not  to  be  estimated  by  the  amount  of  drug 
the  patient  is  receiving,  but  is  to  be  measured  by  the  pa- 
tient's condition  and  clinical  manifestations.  The  mere 
fact  that  a  physician  has  reduced  a  narcotic  addict's 
opiate  intake  from  a  large  dosage  to  a  very  small  dosage, 
or  indeed  has  denied  him  any  opiate  at  all  for  a  consid- 
erable length  of  time,  is  no  evidence  that  he  is  curing  or 


76    THE  NARCOTIC  DRUG  PROBLEM 

has  cured  his  patient  of  addiction-disease.  Unless  the 
physical  mechanism  of  body-need  for  an  opiate  has  been 
completely  and  actually  quieted,  the  patient  may  have  in 
his  body  for  perhaps  weeks  and  months  after  the  last  ad- 
ministration of  the  drug,  a  physical  demand  for  it.  The 
taking  of  opiate  does  not  constitute  opiate  addiction-dis- 
ease. Also  the  mere  fact  that  an  addict  is  no  longer  tak- 
ing opiate  does  not  constitute  proof  that  he  is  ^'  cured  " 
of  opiate  addiction.  The  non-recognition  of  this  fact 
lies  at  the  root  of  much  past  failure.  The  general  axio- 
matic statement  might  be  that  an  addict  should  be  supplied 
with  the  drug  of  his  addiction  to  the  complete  extent  of  his 
physical  need  at  any  given  time  until  conditions  are  right 
for  the  undertaking  of  assuredly  competent  opiate  with- 
drawal and  complete  arrest  of  his  addiction-disease 
mechanism. 

The  mere  amount  of  drug  used  by  a  patient  in  twenty- 
four  hours  is  a  matter  of  minor  importance  compared  with 
the  general  health,  physical  tone,  nervous  glandular  and 
functional  balance,  reaction  and  resistance  of  that  patient. 
Also  the  amount  of  drug  taken  by  a  patient  in  twenty- 
four  hours  is  absolutely  no  adequate  measure  of  the 
strength  or  stage  of  development  of  his  addiction-disease. 
If  he  does  not  get  enough  opiate  he  cannot  competently 
functionate;  he  cannot  be  adequately  nourished;  he  can- 
not sufficiently  eliminate.  He  is  subjected  to  the  in- 
fluences of  constant  discomfort  and  nerve  strain  in  the 
endurance  of  low-grade  withdrawal  manifestations.  He 
is  worried  and  becoming  exhausted.  It  becomes  apparent 
that  by  continued  maintainance  of  narcotic  administration 
below  the  amount  of  physical  body-drug-need  the  very  fac- 
tors are  created  which  have  been  described  as  increasing 
body-drug-need.  It  is  difficult  to  see  any  therapeutic  ad- 
vantage in  such  a  situation.  Moreover,  as  has  been  stated 
before,  it  is  far  easier  to  eradicate  completely  and  sue- 


NARCOTIC  DRUG  ADDICTION-DISEASE     77 

cessfully  narcotic  drug  need  in  a  short  time  and  without 
marked  discomfort,  from  a  functionally  competent  and 
organically  healthy  man  who  is  taking  a  physically  suffi- 
cient amount,  than  it  is  from  a  nerve-racked,  worried  and 
physically,  nervously,  and  functionally  exhausted  wreck 
who  is  under-dosed. 

It  is  therefore  much  wiser  to  direct  immediate  efforts  to 
the  securing  and  maintaining  of  health,  reaction  and  tone 
—  irrespective  of  the  amount  of  drug  required  —  until 
there  is  time  and  opportunity  for  the  undertaking  of  com- 
petent withdrawal  —  a  stage  of  handling  and  treatment 
concerning  whose  physical  and  clinical  phenomena  and 
manifestations  and  dangers  too  few  are  educated  to  and 
familiar  with. 

In  regulating  the  administration  of  drug  as  to  size  and 
intervals  of  dosage  —  amounts  should  be  sufficient  to  allow 
the  patient  long  intervals  between  doses.  In  the  deter- 
mination of  this,  it  is  necessary  to  study  and  experiment 
with  the  reactions  in  the  individual  case.  The  effort,  how- 
ever, should  be  to  have  the  drug  administered  the  smallest 
possible  number  of  times  in  the  twenty-four  hours  com- 
patible with  the  patient's  well-being.  Eor  example  —  if 
a  given  patient's  daily  need  is  three  grains  a  day,  it  is 
much  wiser  to  administer  this  amount  of  drug  in  doses  of 
one  grain  three  times  a  day  or  a  grain  and  a  half  twice 
a  day  as  soon  as  practicable,  than  it  is  to  have  it  admin- 
istered in  larger  numbers  of  smaller  doses  at  more  fre- 
quent intervals.  The  reason  is,  that,  apparently  after  a 
dose  of  narcotic  drug  is  administered  function  is  inhibited 
for  a  length  of  time  which  is  not  in  proportion  to  the 
size  of  the  dose  administered.  On  the  other  hand,  as 
has  been  stated,  within  limits,  the  length  of  time  over 
which  a  dose  of  narcotic  drug  will  hold  a  patient  in  drug 
balance  and  free  from  the  physical  manifestations  of  drug 
need  is  in  proportion  to  the  size  of  the  dose.     Therefore 


78    THE  NARCOTIC  DRUG  PROBLEM 

large  doses  at  wide  intervals  permit  greatest  freedom  from 
functional  inhibition  and  as  well,  if  not  better,  supply 
the  demands  of  physical  drug  need. 

I  have  briefly  referred  to  the  elements  of  intestinal  and 
autointoxication  and  autotoxicosis.  Intestinal  and  autoin- 
toxication, combined  with  worry,  fear,  and  anxiety,  con- 
stitute very  important  causative  and  controlling  factors  in 
whatever  mental  and  physical  deterioration  has  taken  place 
in  a  case  of  narcotic-drug-addiction-disease.  Physical, 
mental  and  moral  deterioration  are  to  a  very  small  extent 
direct  results  of  narcotic  drug  action  per  se.  As  long  as 
a  narcotic  drug  addict  is  maintained  non-toxic,  uninhibited 
and  unworried,  he  is  practically  at  his  individual  normal, 
plus  an  added  physical  need.  It  should  not  be  necessary 
to  recall  to  memory  many  cases  of  upright,  honorable 
and  competent  and  apparently  healthy  men  and  women 
who  have  been  narcotic  addicts  over  very  many  years, 
unknown  to  but  very  few  or  none  of  their  relatives  or 
friends  or  even  physicians.  As  has  been  stated  before, 
their  apparent  immunity  to  the  supposed  stigmata  of  nar- 
cotic drug  action  was  not  due  to  the  fact  that  they  were 
on  a  higher  mental  or  moral  plane  than  their  less  for- 
tunate fellows,  or  that  they  were  possessed  of  sufficient 
will-power  to  resist  temptation  in  the  over-indulgence  of 
their  so-called  appetite.  The  facts  are  that  by  experience 
they  found  out  that  if  they  used  narcotic  drug  in  amounts 
indicated  by  the  manifestations  of  their  disease,  and  did 
not  take  it  too  often  and  kept  their  bowels  open  and  did 
not  worry,  they  were  as  normal  as  anybody  else  except  for 
the  fact  that  they  had  to  take  a  dose  of  a  certain  medicine 
two  or  three  times  a  day.  In  other  words  they  simply 
learned  to  manage  their  disease  in  a  way  to  avoid  compli- 
cations. They  met  their  issue  squarely;  they  discounted 
theory  and  recognized  facts,  and  they  used  common  sense 
in  the  interpretation  and  application  of  what  they  learned. 

The  control  of  auto  and  intestinal  intoxication  in  nar- 


NARCOTIC  DRUG  ADDICTION-DIEASE     79 

cotic  addiction  is  as  a  rule  of  easy  accompli shment  if  the 
patient  is  -uninhibited  and  in  functional  balance  and  is 
not  over-supplied  or  under-supplied  with  the  drug  of  his 
addiction.  The  narcotic  addict  who  is  non-toxic  and  in 
drug  balance  and  is  not  harassed  by  worry  or  fear  needs 
practically  no  more  drastic  methods  of  elimination  than 
his  non-addicted  brother.  If  he  is  over-dosed  his  elimina- 
tion is  inhibited ;  if  he  is  under-dosed  his  eliminative  pow- 
ers are  not  capable  of  response.  The  element  in  the  secur- 
ing of  evacuation  of  the  bowel  in  a  drug  case,  as  well  as  in  a 
toxic  case  of  whatever  description,  is  sluggish  peristalsis ; 
in  other  words,  it  is  inhibition  of  nervous  impulse.  It  is 
therefore  not  necessary  to  load  a  bowel  up  with  large 
amounts  of  drastic  and  irritating  cathartics.  Indeed  this 
procedure  is  very  harmful  and  abortive  of  ultimate  results. 
An  over-irritated  intestinal  tract  is  not  a  good  eliminative 
organ.  To  my  mind  the  so-called  "  typical  stool,"  of  the 
so-called  ^'  Towns  Treatment "  with  its  content  of  jelly 
mucus  has  no  clinical  significance  other  than  its  evidence 
of  a  production  of  an  exhaustive  and  irritative  mucous 
colitis  and  means  that  however  much  purging  may  be  ac- 
complished competent  elimination  from  the  colon  is  at  an 
end.  Its  appearance  in  a  case  under  my  oare  I  should 
regard  as  evidence  of  injudicious  treatment.  Eor  the 
bowel  elimination  of  a  case  of  narcotic-addiction  there 
is  needed  practically  nothing  beyond  the  ordinary  mild 
and  non-irritating  catharsis.  All  that  is  needed  is  to  re- 
member that  if  inhibition  of  peristalsis  has  not  as  yet  been 
overcome,  you  may  be  wise  to  administer,  about  the  time 
you  should  get  an  evacuation,  strychnine  or  other  peristal- 
tic stimulators  in  sufficient  amounts  to  overcome  existing 
inhibition  and  stimulate  peristalsis. 

Inhibition  of  function,  as  I  have  already  shown,  is  a  ^\ 
basic  factor  in  the  development  and  maintaining  of  the    | 
narcotic  addiction-disease  state.     It  is  of  great  importance 
to  recognize,  estimate  and  control  its  presence  and  influ- 


80  THE  NARCOTIC  DRUG  PROBLEM 

ence.  Inhibition  of  function  is  due  to  nervous  exhaustion 
from  overwork,  fear,  anxiety  and  suffering;  it  follows  for 
a  few  hours  the  administration  of  opiate  drugs;  it  is  a 
constant  result  of  chronic  constipation  and  of  intestinal 
and  auto-toxemia.  The  rationale  of  its  control  is  evident 
from  the  enumeration  of  its  causes.  Until  its  causative 
factors  have  been  removed  or  controlled,  its  manifestations 
must  be  treated  symptomaticallj  —  remembering  always 
that  for  therapeutic  action  in  an  inhibited  individual  dos- 
age of  medicinal  agents  varies,  and  must  be  estimated 
from  clinical  observation  and  experiment  and  not  from 
memory  of  the  text-books.  To  the  man  experienced  in 
their  use  some  of  the  internal  secretory  glandular  products 
are  at  times  helpful.  As  has  been  stated  above,  strychnine 
or  other  peristaltic  stimulator  is  useful. 

Tinally  I  repeat  again  my  disbelief  in  and  opposition  to 
the  use  of  any  drug  or  combination  of  drugs  under  the 
impression  that  they  have  or  may  have  specific  curative 
action  against  addiction-disease.  Although  I  at  times  em- 
ploy various  of  the  drugs  commonly  mentioned  in  connec- 
tion with  the  treatment  of  addiction,  I  do  so  with  no  belief 
that  they  have  "  specific  "  properties  in  this  disease.  I 
use  them  in  the  treatment  of  addiction  as  I  do  in  other 
disease  conditions,  simply  and  solely  as  they  meet  individ- 
ual clinical  and  therapeutic  indications.  Petty  took  this 
stand  years  ago.  I  do  not  regard  these  dnigs  as  curative 
of  addiction-disease,  and  I  do  not  constantly  use  any  of 
them. 

I  do  not  use  or  endorse,  a  "  belladonna  "  treatment,  a 
"  hyoscine  "  treatment,  nor  any  other  description  of  specific 
or  routine  treatment  in  addiction-disease.  I  regard  the 
drugs  of  the  belladonna  and  hyoscyamus  groups,  pilocar- 
pine, etc.,  as  extremely  dangerous  drugs  to  be  routinely  or 
carelessly  used  in  the  treatment  of  addiction-disease. 
They  are  rendered  safe  only  after  personal  experience  and 
study  into  their  action  and  appreciation  of  the  factors  and 


NARCOTIC  DRUG  ADDICTION-DISEASE     81 

influences  which  control  their  action  in  the  functional, 
toxic,  and  narcotic  drug  conditions.  The  routine  and  un- 
intelligent use  of  the  products  of  these  groups  of  drugs  in 
the  treatment  of  narcotic  addiction  —  under  the  mistaken 
impression  that  they  somehow  or  other  have  direct  curative 
action  upon  the  disease  condition  —  has  been  the  cause  of  a 
considerable  mortality  and  an  easily  understood  opposition 
among  intelligent  addicts.  Hyoscine  or  scopolamine  and 
the  other  members  of  this  group,  ezerine,  pilocarpine, 
the  coal  tar  products,  etc.,  are  at  times  useful  drugs  to 
meet  indications  in  the  treatment  of  a  case  of  addiction. 
Increasing  intelligence  in  the  handling  of  the  addiction 
mechanism  itself,  however,  renders  the  necessity  of  their 
use  less  and  less  frequent  and  the  dosage  of  them  required 
for  therapeutic  action  smaller  and  smaller.  They  should 
simply  be  classed  as  of  use  among  other  things,  peristaltic 
and  circulatory  stimulation  and  support,  indicated  elimi- 
nants,  kindness  and  consideration,  understanding  and  in- 
telligence or  any  of  the  other  therapeutic  weapons  in  our 
possession. 

Elimination  and  the  securing  of  it  in  the  narcotic  ad- 
dicted has  been  referred  to  in  this  chapter.  The  chapter 
should  not  be  closed  however,  without  a  word  of  warning 
against  the  excessive  purgation  with  drastic  and  over  irri- 
tating agents  employed  by  some  in  this  condition.  Drastic 
purgation  is  not  at  all  synonymous  with  competent  elimina- 
tion. Competent  elimination  is  not  to  be  measured  in 
terms  of  bowel-movements ;  but  in  terms  of  clinical  symp- 
tomatology of  toxemia,  circulation  and  measure  of  func- 
tional efficiency.  Excessive  purgation  means  over-irrita- 
tion and  over-stimulation  of  eliminative  mechanism,  re- 
sults in  the  interference  with  and  exhaustion  of  function 
and  defeats  true  elimination. 

Presence  of  good  circulatory  tone  and  absence  of  con- 
gestion in  the  eliminative  organs  is  to  me  one  of  the  most 
important  factors  in  true  elimination.     The  addict  who 


82  THE  NARCOTIC  DRUG  PROBLEM 

is  in  good  functional  tone,  has  competent  circulation,  is  in 
narcotic  drug  balance,  and  is  noninhibited,  needs  no  more 
drastic  eliminative  measures  than  belong  to  ordinary  ra- 
tional therapeutics  in  the  nonaddicted. 

As  to  final  withdrawal  of  the  drug,  and  ultimate  arrest 
of  the  disease,  I  shall  say  but  little  in  this  book. 

I  follow  no  "  routine  "  and  have  no  set  procedure.  I 
am  guided,  as  in  my  handling  of  the  other  stages  of  addic- 
tion-disease, by  the  condition  of  my  patient  and  his  clinical 
requirements.  There  is  no  one  procedure  applicable  to 
all  cases  of  any  condition  in  medicine  and  surgery.  In 
narcotic  addiction-disease,  as  in  all  other  conditions  of 
medicine  and  surgery,  the  man  who  will  have  the  best 
results  is  the  man  who  is  possessed  of  the  widest  and  most 
varied  experience  combined  with  intelligent  observation, 
technical  skill  and  clinical  judgment  in  the  selection  of 
procedure  best  adapted  to  the  needs  of  the  individual  case. 
Familiarity  and  experience  with  different  methods  and 
procedures  reveals  in  each  and  nearly  all  of  them  some 
advantages  and  some  defects.  The  wise  man  and  the  man 
whose  results  will  most  approach  uniform  success  is  he 
who  can  make  intelligent  selection  and  use  of  whatever  is 
most  applicable  to  the  needs  of  the  case  he  treats,  either  out 
of  his  own  experience  and  discoveries,  or  out  of  his  famil- 
iarity with  the  work  of  others. 

An  element  in  successful  withdrawal  of  narcotic  must 
also  remain,  as  in  everything  else,  the  inherent  personal 
gifts  and  qualifications  of  the  individual  operator.  A 
man  works  best  with  the  tools  most  adapted  to  his  hand, 
and  operators  of  different  temperaments  and  of  different 
experience  and  training  will  always  disagree  on  points  of 
procedure  and  technique.  My  own  procedure  in  final 
withdrawal  is  determined  largely  by  my  study  and  measure 
of  my  patient  and  my  patient's  reactions,  addiction  and 
otherwise,  during  my  preliminary  or  preparatory  work, 


NARCOTIC  DRUG  ADDICTION-DISEASE     83 

selecting  the  time  for  final  withdrawal  of  drug  by  con- 
sideration of  similar  factors  as  would  be  taken  into  account 
in  an  operation  of  election. 

After  a  preliminary  stage,  or  stage  of  preparation,  in 
w^hich  I  have  gotten  rid  of  all  possible  abnormalities, 
physical  and  psychical,  with  my  patient  robust  and  re- 
active, confident  and  expectantly  happy,  with  autointoxica- 
tion, and  inhibition  removed  and  the  possible  residues  of 
opiate  or  opiate  product  no  longer  stored  in  atonic  body 
cells  —  the  addiction-mechanism,  therefore,  only  kept  in 
activity  by  the  current  intake  of  opiate,  which  if  properly 
handled  and  the  patient  not  subjected  to  exhausting  strain 
and  struggle  and  suffering,  can  be  eliminated  in  a  very 
short  time.  With  these  conditions  consummated,  I  hasten 
elimination,  keeping  well  away  from  exhausting  purgation, 
maintaining  my  patient's  circulatory  and  other  functions, 
and  conducting  as  rapid  a  withdrawal  as  is  compatible 
with  my  patient's  reactive  condition  and  the  reactions  of 
his  disease. 

In  other  words,  I  endeavor  by  my  conduct  of  the  case 
to  reverse  the  process  of  development  of  the  physical  addic- 
tion-disease with  its  concomitants  and  complications,  as  I 
find  it  in  the  individual  case,  arresting  the  addiction- 
disease  mechanism  only  after  I  have  cleared  the  clinical 
picture  in  so  far  as  possible  of  all  other  considerations. 

In  a  majority  of  cases  by  experienced  choice  of  clinical 
procedure,  combined  with  judgment  and  technical  skill, 
the  arrest  of  addiction-mechanism  and  the  restoration  of 
the  narcotic  addict  to  health  and  freedom  from  both  opiate 
need  and  thought  of  opiate  drug  is  a  matter  of  assured 
accomplishment  attended  by  little  if  any  nervous  strain 
and  physical  suffering. 

Ability  to  accomplish  this  is  not  beyond  the  power  of 
any  competent  practitioner,  whether  he  reside  in  a  hospital 
or  is  in  private  practice.     All  that  is  required  is  instruc- 


84j  the  narcotic  DRUG  PROBLEM 

tion  or  information  as  to  the  mechanism  of  addiction- 
disease,  clinical  demonstration  of  its  manifestations  and 
reactions  and  the  same  amount  of  experience  in  their 
handling  as  is  expected  of  a  man  who  treats  any  other 
disease. 

I  have  purposely  refrained  in  this  book  from  discussion 
of  technical  details  of  therapeutic  procedures,  and  of  vari- 
ous medications,  and  of  their  various  indications,  contra- 
indications, applications,  dosage,  etc.  Such  discussion,  to 
be  adequate  and  competent,  would  require  much  space  and 
would  distract  from  the  general  presentation  of  the  prob- 
lem, which  is  the  purpose  of  this  volume. 

I  have  learned  from  experience  in  teaching  and  in 
treatment  of  cases  that  before  there  has  been  established 
appreciation  of  the  whole  personal  and  clinical  problem 
and  picture,  and  conception  of  its  disease  mechanism,  and 
ability  clinically  to  recognize  and  interpret  symptomatol- 
ogy, discussion  of  technical  details  is  premature  and  mis- 
leading. 


CHAPTEE  VII 

EELATIOIi  OP  iq'AECOTIC  DRUG  ADDICTION  TO'  SURGICAL,  CASES 
ANjy  INTEECUREENT  DISEASES 

It  is  a  conunon  idea  in  tlie  minds  of  botli  surgeons  and 
physicians  tliat  an  addict  to  narcotic  drug  is  a  difficult 
case  for  surgical  handling  and  is  a  poor  surgical  risk. 
ISTumerous  instances  of  surgeons  refusing  to  operate  upon 
a  narcotic  addict  until  the  addict  should  have  "  stopped '' 
the  use  of  the  drug^  voice  the  almost  prevailing  attitude. 

Very  many,  if  not  most,  internists  and  practitioners 
view  with  gravest  concern  the  presence  of  addiction  in  a 
serious  illness  coming  under  their  care. 

That  the  addict  has  borne  this  undeserved  reputation  as 
a  poor  surgical  and  medical  risk,  and  that  this  reputation 
has  been  seemingly  merited  by  previous  medical  and  surg- 
ical experience,  is  not  to  be  laid  at  the  door  of  the  exist- 
ence of  addiction  in  the  patient.  It  is  to  be  laid  at  the 
door  of  insufficient  medical  comprehension  of  addiction- 
disease  and  its  mechanism  in  its  material  manifestations, 
and  in  its  functional  and  organic  influences,  and  at  the 
door  of  inadequate  clinical  study  into  the  analysis,  estima- 
tion and  control  of  these.  Like  much  else  that  has  been 
for  generations  generally  accepted  as  true  about  narcotic 
drug  addiction,  the  belief  is  erroneous  that  the  addict  is 
a  poor  surgical  and  medical  risk  because  he  is  an  addict. 

As  a  surgeon  once  stated  "  These  addicts  have  no  resist- v 
ance,  and  they  go  right  out."     Swayed  by  the  old  concep- ' 
tion  of  addiction,  this  more  than  ordinarily  humane  and 
generous-hearted  man  had  not  the  slightest  suspicion  as 
to  why  the  addicts  that  he  had  operated  upon  had  displayed 

i  85 


86     THE  NARCOTIC  DRUG  PROBLEM 

no  resistance  and  had  tended  to  "  go  right  out/'  He  had 
in  his  mind  simply  the  then  prevailing  and  practically 
unquestioned  conception  of  the  narcotic  addict,  and  he  had 
not  the  slightest  suspicion  that  a  definite  physical  disease, 
whose  mechanism  should  have  received  intelligent  clinical 
handling  and  control  was  complicating  the  surgical  cases 
of  the  addicts  who  went  right  out.  He  had  based,  as  all 
of  us  once  did,  his  opiate  medication  on  his  materia  medica 
conception  of  therapeutic  dosage  instead  of  on  the  demands 
of  an  addiction-disease  mechanism.  It  is  rumored  that 
more  than  one  illustrious  life,  full  of  past  accomplishment 
and  potential  future  benefit  to  humanity  and  society,  has 
ended  in  this  way. 

The  above  statements  do  not  apply  to  surgery  alone. 
They  are  equally  true  of  medical  conditions.  Dominated 
by  their  teachings  as  to  opiate  dosage  in  ordinary  therapeu- 
tics, and  by  the  older  ^'  habit "  conception  of  addiction, 
with  little  or  no  instruction  as  to  the  dosage  indications 
of  addiction-disease,  most  practitioners,  institutional  and 
private,  do  not  adequately  conceive  and  have  no  basis  for 
determination  of  opiate  dosage  in  this  disease.  They  do 
not  believe  that  the  addict  physically  needs  nor  do  many 
of  them  realize  that  the  addict  can  physically  tolerate  what 
seems  to  them  such  dangerous  and  lethal  amounts,  and 
they  tend  to  ascribe  his  statements  of  usual  dosage  to 
mental  "  cravings  "  to  which  they  refuse  to  pander.  Many 
appreciate  that  such  patients  have  often  to  be  very  care- 
fully watched  to  prevent  their  suicide  and  that  many  of 
them  die,  but  fail  to  comprehend  that  these  events  may 
be  ascribed  to  inability  to  longer  endure  the  suffering  and 
physical  incompetency  of  body-need  for  opiate  medication. 

The  recent  epidemic  of  influenza  and  pneumonia  fur- 
nishes examples  of  the  importance  of  recognizing  addic- 
tion-disease mechanism  in  intercurrent  diseases.  A  num- 
ber of  instances  have  come  to  my  attention.  One  of  them 
is  of  particular  interest  because  of  the  graphic  picture 


SURGICAL  CASES  87 

presented  by  a  series  of  sphygmograpliic  tracings  showing 
the  physical  organic  dependence  upon  opiate  in  the  cir- 
culation of  an  addict.  It  may  be  said  in  passing  that 
these  tracings  and  others  made  upon  addicts  in  partial 
or  complete  opiate  withdrawal  parallel  similar  tracings 
by  other  clinical  observers^  and  also  those  made  by  ex- 
perimental laboratory  workers  upon  addicted  dogs. 

The  subject  of  these  tracings  was  a  man  well-known 
and  prominent  in  his  community,  63  years  of  age,  suf- 
fering from  pneumonia  with  marked  and  persisting 
cardiac  and  circulatory  deficiency  which  did  not  respond 
to  the  administration  of  the  usual  circulatory  stimulants 
even  in  very  large  doses.  I  was  called  in  consultation. 
Found  the  patient  very  weak  and  exhausted,  with  facial 
expression  of  protracted  suffering  and  anxiety  and  de- 
spondency. Morphine  in  usual  therapeutic  doses  had 
been  daily  administered  for  relief  of  pain,  restlessness 
and  sleeplessness,  being  insufficient  however  to  control 
those  manifestations.  Pulse  was,  as  shown  in  tracing 
number  1,  very  weak  and  intermittent.  It  was  impos- 
sible to  account  for  the  whole  clinical  picture  and  history 
on  the  grounds  of  a  typical  pneumonia,  present  or  re- 
solving. Opiate  addiction  was  suspected  and  the  patient 
questioned.  He  had  been  suffering  from  opiate  addic- 
tion-disease for  many  years,  his  addiction  developing  un- 
suspected by  him  as  a  result  of  medication  for  a  painful 
and  protracted  condition  many  years  previous.  He 
begged  to  be  allowed  to  die  without  his  wife  and  son  being 
told  of  his  affliction.  The  following  tracings  made  upon 
him  are  very  instructive  and  significant,  and  cannot  be 
interpreted  upon  any  grounds  of  psychical  explanation  of 
addiction  phenomena. 

The  last  dose  of  morphine  prior  to  these  tracings  was 
one-eighth  of  a  grain  given  at  3  :30  p.  m. 

First  tracing  (number  1)  was  made  about  6:00  p.  m. 

Tracings  2,  3  and  4  were  made  at  about  fifteen  minute 


88  THE  NARCOTIC  DRUG  PROBLEM 

(Chart  of  Sphygmographic  Tracings) 


SURGICAL  CASES  89 

intervals.  They  were  made  following  experimental  hypo- 
dermic injections  of  morphine  sulphate  to  determine  the 
extent  of  opiate  need  and  organic  dependence  upon  opiate 
medication,  and  the  amount  of  opiate  required  to  restore 
organic  function  and  tone. 

Tracing  numher  4,  taking  into  consideration  the 
asthenic  and  exhaustion  condition  of  the  patient,  shows 
full  support  to  circulation  with  some  overaction. 

Tracing  number  5  was  taken  an  hour  or  two  after  trac- 
ing numher  4  to  determine  the  holding  power  of  the 
dosage  administered,  after  the  circulation  had  reacted 
from  the  immediate  stimulation  of  the  opiate  medication. 
This  tracing,  interpreted  and  considered  together  with 
the  clinical  manifestations  at  the  time,  was  decided  to 
be  about  normal  for  that  patient  at  that  time. 

.  This  patient  would  have  died,  not  from  pneumonia  with 
cardiac  complications,  but  from  insufficient  control  of  the 
mechanism  of  opiate  addiction-disease. 

On  balanced  and  indicated  daily  morphine  dosage, 
patient  made  very  rapid  recovery  and  has  continued  well 
and  active. 

Such  cases  as  this,  where  addiction-disease  co-exists  or 
is  intercurrent  with  other  medical  or  with  surgical  con- 
ditions, are  not  as  uncommon  as  may  be  supposed.  That 
they  are  frequently  unrecognized  the  histories  of  many 
narcotic  addicts  demonstrates,  and  is  discussed  later. 
Board  of  Health  and  Insurance  mortality  statistics  are 
undoubtedly  very  incomplete  upon  this  situation.  Ad- 
diction, regarded  as  a  habit  or  indulgence,  may  easily  be 
overlooked  or  disregarded  as  a  cause  of  death,  direct  or 
contributing.  It  may  easily  be  omitted  from  returns 
made  out,  however  actually  important  a  part  in  the  final 
issue  may  have  been  played  by  the  influences,  upon  body 
function  and  upon  physical  resistance  and  recuperation, 
of  an  unappreciated  and  inadequately  controlled  addic- 
tion-disease. 


90     THE  NARCOTIC  DRUG  PROBLEM 

It  is  earlier  stated  that  tlie  common  idea  of  the  addict 
to  narcotic  drugs  as  a  poor  risk  is  an  undeserved  reputa- 
tion, and  is  not  to  be  laid  at  the  door  of  addiction  exist- 
ence itself.  In  very  many  cases  of  opiate  addiction,  the 
opposite  of  the  popular  belief  is  true.  The  opiate  addict, 
if  his  addiction  mechanism  is  competently  appreciated,  its 
reactions  accurately  estimated,  and  its  influences  wisely 
controlled,  is  quite  other  than  a  bad  risk.  Indeed  the  me- 
chanism of  addiction  and  the  opiate  v^hich  caused  it  can 
often  be  handled  in  such  a  v^ay  in  the  control  of  glandular, 
circulatory,  nervous  and  other  function  and  reaction  as  to 
aid  in  the  carrying  over  of  emergencies,  medical  and 
surgical.  A  case  in  point  is  an  emergency  operation  on 
the  pancreas,  performed  upon  a  man  in  extremis,  v^hose 
unexpected  recovery  and  convalescence  astonished  all  ob- 
servers by  being  remarkedly  rapid  and  uncomplicated, 
due  unquestionably  in  large  part  to  the  early  recognition 
and  clinical  handling  of  his  addiction-disease,  and  the 
possibilities  it  created  for  unusual  opiate  medication. 

It  has  been  my  experience  at  times,  when  called  in 
medical  consultation  upon  post-operative  cases  whose 
lack  of  repair  and  slowness  of  recovery  could  not  be  ac- 
counted for,  to  discover  an  unsuspected  addiction,  and  to 
find  that  the  lack  of  repair  and  slowness  of  recovery  was 
due  simply  and  slowly  to  the  want  of  comprehension  of, 
or  to  inadequate  control  of  addiction  mechanism  existing 
in  the  patient. 

Many  opiate  addicts  when  about  to  undergo  operation, 
have  provided  for  possible  contingencies  by  the  conceal- 
ment of,  or  by  outside  provision  for,  a  supply  of  opiate 
sufficient  in  amount  to  meet  their  physical  needs.  There 
are  very  many  addicts  who  have,  out  of  their  past  ex- 
perience and  study  upon  themselves,  competently  con- 
trolled their  own  narcotic-drug-disease  during  treatment 
for  other  conditions,  operative  or  medical.  The  number 
of  narcotic  addicts  is  not  few  who  have  been  cared  for 


SURGICAL  CASES  '        91 

medically  with  nursing  attention,  or  have  undergone  op- 
erations for  the  remedy  of  various  surgical  conditions, 
have  recovered,  convalesced  and  been  discharged  with- 
out the  physician  or  surgeon  becoming  aware  that  his 
patient  was  addicted.  This  is  not  a  comment  in  criticism 
upon  my  professional  brethren.  In  my  own  experience 
such  a  case  is  a  matter  of  quite  recent  occurrence.  A 
patient  treated  by  me  in  a  hospital,  for  conditions  other 
than  addiction,  one  day  unexpectedly  revealed  to  me  the 
fact  of  long  standing  addiction.  The  patient  had  been 
afraid  to  tell  me  about  this  condition  until  thoroughly 
convinced  of  my  attitude  towards  it,  and  had  secured 
opiate  medication  elsewhere. 

It  seems  strange  that  a  condition  of  as  powerful  in- 
fluence over  body  function  and  metabolism  as  is  exerted 
by  the  addiction  mechanism  of  narcotic  drug-disease 
should  not  long  ago  have  received  exhaustive  and  com- 
plete clinical  and  laboratory  study  along  the  lines  of  its 
manifestations  and  influences_,  as  well  as  along  the  line 
of  reduction  and  deprivation  of  the  drug  of  addiction. 
In  view  of  the  above  it  would  seem  to  be  of  vastly  more 
importance  at  the  present  time  that  the  mass  of  practi- 
tioners of  surgery  as  well  as  of  medicine  should  under- 
stand and  be  able  to  control  action  and  reaction  in  a  nar- 
cotic addict  as  a  result  of  his  addiction-disease  mechanism, 
than  it  is  that  they  should  attempt  the  mere  reduction  or 
denial  of  the  drug  of  addiction. 

Appreciation  of  the  above  would  make  available  to  nar- 
cotic addicts,  suffering  from  other  conditions,  hospital  and 
professional  treatment  and  remedy  of  those  conditions. 
Under  present  prevailing  conceptions  of  addiction,  many 
honest  and  worthy  people  addicted  to  opiates  dare  not 
avail  themselves  of  needed  treatment  for  medical  condi- 
tions or  operation  for  surgical  conditions  because  of  their 
uncertainty  regarding  the  attitude  towards  and  handling 
of  addiction-disease  existing  in  and  carried  out  by  the  in- 


92     THE  NARCOTIC  DRUG  PROBLEM 

stitution  or  practitioner  to  whoin  they  would  ordinarily 
appeal  for  help.  The  addict  lives  in  constant  fear  of 
some  injury  or  illness  which  may  necessitate  his  coming 
into  the  hands  of  those  whose  conception  of  addiction  is 
not  in  accord  with  the  addict's  experience  of  addiction- 
disease  facts. 

As  I  have  emphasized  in  previous  chapters,  the  actual 
withdrawing  of  opiate  from  an  addict  is  simply  one  stage, 
and  by  no  means  the  most  important  stage  in  the  rational 
consideration  and  handling  of  a  case  of  narcotic  drug 
addiction.  The  fact  that  a  patient  is  using  an  opiate 
drug,  and  that  he  uses,  within  reasonable  limits,  a  larger 
or  smaller  amount  of  that  drug,  is  a  matter  of  very  minor 
importance  as  compared  with  his  general  functional, 
nutritional,  and  metabolic  efficiency.  This  is  true  as  a 
general  proposition  in  the  handling  of  any  case  of  nar- 
cotic drug  addiction,  and  is  vastly  more  true  in  the  hand- 
ling of  cases  of  other  conditions  or  diseases,  operative  or 
otherwise,  that  are  complicated  by  narcotic  drug  addiction- 
disease.  The  physician  or  surgeon  should  realize  that 
the  use  of  a  narcotic  drug  by  a  patient  under  his  care 
is  of  very  little  immediate  importance  compared  with  the 
satisfactory  recovery  of  his  patient  from  the  condition  for 
which  he  is  treating  him.  The  physician  or  the  surgeon 
who  has  in  his  care  a  narcotic  drug  addict  whom  he  is 
treating  for  another  disease  condition  should  remember 
that  the  patient's  recovery  from  the  condition  for  which 
the  doctor  was  consulted,  depends  to  a  great  extent  upon 
the  amount  of  functional  balance  and  organic  and  meta- 
bolic adequacy  which  exists  in  that  patient,  and  he  should 
realize  that  functional  balance  and  organic  and  metabolic 
adequacy  in  a  narcotic  addict  are  largely  under  the  con- 
trol of,  and  vary  with  the  extent  to  which  that  patient  is 
kept  in,  adequate  narcotic  drug  balance. 

The  establishing  and  maintaining  of  adequate  drug  bal- 
ance, therefore,  is  one  of  the  most  important  elements  to 


SURGICAL  CASES  93 

be  considered  in  the  conduct  of  a  case  of  narcotic  addiction 
undergoing  operation  or  treatment  for  a  condition  other 
than  the  cure  of  his  addiction.  In  handling  such  a 
patient,  the  physician  or  surgeon  should  completely  put 
out  of  his  mind  any  idea  of  at  the  same  time  trying  to 
"  cure  "  the  addiction  with  which  his  patient  is  afflicted. 
I  have  repeatedly  heard  of  many,  and  have  personally 
come  into  contact  with  cases  where  the  physician  or  sur- 
geon was  trying  to  withdraw  opiate  drug  from  a  patient 
with  addiction-disease,  as  an  incidental  in  the  course  of 
treatment  of  other  disease  conditions.  There  are  cases 
of  addiction-disease  in  which  this  may  he  successfully 
accomplished.  In  the  majority  of  cases,  however,  this 
procedure  is  too  harmful  to  be  anything  but  condemned. 
'Not  only  will  the  surgeon  or  physician  ordinarily  fail  in 
his  attempt  to  remedy  the  addiction  condition,  but  he  may 
very  severely  handicap  his  other  work  on  that  patient  and 
very  seriously  jeopardize  the  success  of  his  efforts  in  the 
remedy  of  the  condition  which  he  was  originally  called 
upon  to  treat. 

It  must  be  remembered  that  addiction-disease  is  a 
chronic  condition,  and  that  it  is  practically  never  indicated 
as  a  matter  of  clinical  emergency,  in  a  case  of  established 
addiction,  that  the  opiate  be  immediately  withdrawn.  As 
has  been  previously  stated,  drug  withdrawal  is  very  much 
like  an  operation  of  election  to  be  done  when  the  patient 
is  ready  for  it  and  by  whatever  procedure  is  indicated 
when  the  proper  time  arrives.  The  getting  of  the  patient 
ready  for  it  often  determines,  just  as  is  the  case  in  the 
operation  of  election,  to  a  great  measure,  the  success  of 
the  work  and  the  freedom  from  complications  and 
sequelae. 

Since  the  final  withdrawal  of  drug  is  to  be  regarded 
as  comparable  to  an  operation  of  election,  and  the  best 
time  for  its  execution  is  a  matter  of  arrangement  and  of 
preceding  preparation,  it  is  obvious  that  it  should  not  be 


94  THE  NARCOTIC  DRUG  PROBLEM 

undertaken  witL  expectation  of  satisfactory  issne  in  the 
course  of  treatment  for  an  ailment  or  condition  which 
demands  and  expends  much  physical  resistance  and  re- 
cuperative powers.  Recuperative  forces  should  he  main- 
tained and  directed  towards  whatever  is  the  indication  of 
paramount  importance  at  any  given  time.  In  the  conduct 
of  a  surgical  case  or  a  serious  medical  case,  the  indication 
of  paramount  importance  is  recovery  from  the  condition 
for  which  the  patient  applies  to  the  surgeon  or  physician. 
All  other  conditions  present  should  he  handled  in  such 
a  way  as  to  interfere  as  little  as  possible  with  the  suc- 
cessful accomplishment  of  the  main  issue.  The  proper 
control  of  narcotic  addiction-disease  mechanism  and  of 
its  influences  upon  the  patient  addicted  is  the  important 
problem  presented  by  narcotic  addiction  as  met  in  the 
field  complicating  surgical  and  general  medical  conditions. 


CHAPTEK  VIII 

LAWS,    ANJy   THEIK   EECLATIONS   TO   ITAHCOTIC   DEUGS 

The  first  general  appreciation  of  the  widespread  exist- 
ence of  narcotic  drug  use  was  brought  about  by  the  pas- 
sage of  anti-narcotic  laws.  The  United  States  Federal 
legislation  wbicb  went  into  effect  in  1914,  was  what  is 
known  as  the  Harrison  Law,  still  in  effect  and  in  its  pur- 
pose and  drafting  a  wise  piece  of  legislation.  It  sought 
to  limit  and  control  the  use  of  opiate  drugs  and  cocaine 
by  making  their  possession  and  distribution  illegal  by 
other  than  those  of  professional  and  other  status  designated 
in  the  law,  as  qualified  for  their  intelligent  application 
and  responsible  distribution.  Its  administration  was 
placed  in  the  Department  of  Internal  Eevenue  under  a 
provision  which  licensed  responsible  distributors  and  re- 
quired a  yearly  tax. 

Taken  as  a  whole,  in  its  original  form,  administered 
with  understanding  of  addiction-disease  facts,  and  with 
honest  and  intelligent  scientific,  educational  and  remedial 
activities  coincidently  pursued,  it  should  be  sufficient  to 
control  a  rapidly  growing  menace.  In  its  attitude  to- 
wards the  medical  profession  it  wisely  limited  its  restric- 
tions to  the  broad  statement  that  these  drugs  named  must 
not  be  distributed  other  than  in  the  "  course  of  legitimate 
professional  practice,''  wisely  making  no  attempt  to  de- 
fine such  '^  legitimate  practice,"  but  apparently  anticipat- 
ing investigative  activities  of  the  scientific  professions  in 
the  determination  and  dissemination  of  medical  facts  for 
the  guidance  of  honest  practitioners,  and  of  those  who 
should  interpret  and  enforce  the  law. 

95 


96  THE  NARCOTIC  DRUG  PROBLEM 

Unfortunately  addiction  as  a  disease  was,  at  tKat  time, 
not  a  matter  of  wide  recognition,  the  public  in  general 
and  tlie  medical  profession  itself  still  almost  universally 
holding  to  the  old  conceptions  of  it  on  the  basis  of  sup- 
posed morbid  indulgence  and  '^  habit."  It  seems  to  the 
author  that  the  failure  of  the  Harrison  Law  to  check  or 
limit  the  illegitimate  use  of  the  drugs  it  describes,  is  not 
due  to  a  defect  in  the  law  itself,  but  is  due  to  the  failure 
of  the  scientific  professions  to  clarify  the  situation  with 
a  clean  cut  understanding  of  the  condition  legislated 
against.  jThe  reaction  within  the  medical  profession  as 
"a  resithof  this  law  was  unfortunate.  Instead  of  stimulat- 
ing scientific  interest  and  investigation  into  the  character 
of  this  disease,  the  result  was  that  medical  men  in  gen- 
eral having  little  or  no  conception  of  its  disease  basis,  re- 
garded the  narcotic  addict  as  a  mental  or  correctional 
problem  and  left  his  consideration  and  handling  to  the  lay 
ofiicials  and  the  special  institutions  whose  activities  had 
been  along  other  lines  than  scientific  research  into  physical 
disease. 

In  the  minds  of  most  lay  and  of  many  medical  work- 
ers the  only  consideration  was  the  stopping  of  drug  use 
per  se,  an  attitude  which  to  a  less  extent  still  persists. 
Uninformed  as  to  the  now  established  facts  of  addiction- 
disease,  the  administrators  of  the  law,  and  to  a  large  ex- 
tent the  medical  profession,  tended  to  regard  supply  of 
opiate  to  an  addict  as  the  prolongation  of  a  habit,  and 
not  as  medication  indicated  by  the  mechanism  and  sympto- 
matology of  a  disease  —  and  therefore  as  not  being  legiti- 
mate medical  practice.  This  attitude  had  the  effect  of 
making  the  practitioner  of  medicine  unwilling  to  receive 
the  narcotic  addict  as  a  patient. 

The  immediate  result  was  the  sudden  deprivation  of 
opiate  to  such  addiction-disease  sufferers  as  had  not  had 
financial  means  or  foresight  to  purchase  large  reserves 
before   the   laws  went   into   effect.     The   history   of   the 


LAWS  AND  THEIR  RELATIONS  97 

drastic  early  enforcement  of  the  various  laws,  reduplicated 
with  more  or  less  completeness  by  periodical  legislative 
and  administrative  activities,  without  adequate  arrange- 
ment for  the  relief  of  the  narcotic-deprived  addiction- 
disease  sufferer,  shows  suicides  and  deaths,  and  a  rapid 
development  of  exploitation  of  the  needs  of  the  addict 
at  the  hands  of  illicit  commerce.  Eor  this  illicit  com- 
merce the  laws  themselves,  however,  are  not  so  much  to 
be  blamed  as  the  influence  of  long-prevailing  and  widely- 
taught  attitudes  and  conceptions  which  caused  scientific 
and  other  forces  to  fail  to  recognize  and  meet  the  need 
for  clinical  handling  of  the  situation,  and  for  study  and 
investigation  of  the  condition.  Legislators  and  adminis- 
trators simply  reflect  prevailing  theories. 

Early  theories  took  scant  if  any  account  of  the  possibili- 
ties presented  by  the  now  rapidly-growing  disease  con- 
ception of  addiction.  The  popular  conception  of  an 
addict  and  even  the  description  met  in  standard  medical 
text-books  was  that  of  a  "  dope-fiend,''  an  irresponsible 
panderer  to  a  morbid  ^'  habit,"  bereft  of  will-power,  honor 
and  decency,  a  menace  to  himself  and  to  society,  and  this 
conception  has  had  unfortunate  influence  in  the  making, 
interpretation,  and  administration  of  laws.  That  it  can 
be  truthfully  applied  to  some  people  who  have  developed 
addiction-disease  is  unquestioned,  but  that  it  fails  to  take 
into  consideration  a  much  larger  number  who  are  not 
irresponsible  panderers  to  morbid  habit,  nor  bereft  of  will- 
power, honor  and  decency,  nor  a  menace  to  themselves  or 
to  society,  but  are  honest  and  upright  members  of  society 
and  economic  assets  in  the  community,  accounts  in  large 
part  for  the  failure  of  laws  and  their  administration  to 
remedy  the  narcotic  drug  situation.  Measures  which 
might  be  very  useful  in  the  forcible  control  of  those  who 
can  be  justly  characterized  as  "  dope  fiends  "  work  great 
harm  to  those  who  are  simply  sick  people. 

That  these  sick  people  have  been  commonly  regarded 


98     THE  NARCOTIC  DRUG  PROBLEM 

and  classed  as  "  dope-fiends  "  was  due  to  the  fact  that  the 
points  of  view  and  special  experiences  of  the  psychologist 
or  psychiatrist,  sociologist  or  penologist  and  the  exponents 
of  special  methods  of  treatment  dominated  the  literature 
and  teaching  in  which  appeared  practically  nothing  of 
essential  pathology,  symptomatology  and  broad  principles 
of  addiction-disease  therapeutics  and  handling.  The  oc- 
casional voice  of  the  clinical  student  or  experimental 
laboratory  worker  was  almost  unheard,  and  the  opposition 
accorded  unorthodox  views  and  announcements  made  him 
a  brave  man  who  would  state  them,  and  tended  to  cause 
him  to  be  regarded  as  an  academic  theorist,  or  possessed 
of  ulterior  motives. 

In  such  a  situation  the  dominant  theme  has  been  the 
stamping  out  of  so-called  ^^  drug  use."  The  physician 
who  under  his  best  and  honest  therapeutic  judgment 
strove  to  meet  the  immediate  indications  of  the  worthy 
and  innocent  addiction-disease  sufferer  by  the  administra- 
tion of  opiate  drug,  incurred  a  danger  of  severe  criticism 
and  at  times  of  jeopardy  to  his  liberties  under  the  inter- 
pretation of  his  acts  as  perpetuating  a  "  habit." 

It  cannot  be  denied  that  in  some  cases  unscrupulous 
holders  of  medical  degrees  have  availed  themselves  of 
existing  conditions  in  such  a  way  that  their  supplying  of 
opiates  to  narcotic  addicts  constitutes  simply  traffic  in 
narcotic  drugs  and  not  the  intelligent  practice  of  medicine. 
It  should  be  a  matter  of  serious  consideration  for  our  law- 
makers, administrators  and  judiciary,  however,  as  to  what 
extent  the  performance  of  the  occasional  medical  vampire 
should  be  made  a  basis  for  the  legal  or  administrative  con- 
trol of  the  honest  practitioner,  and  to  what  extent  he 
should  be  enveloped  by  legal  and  administrative  restric- 
tions, the  innocent  and  unconscious  violation  of  whose 
technicalities  may  at  any  time  be  made  a  basis  for  criminal 
procedure.  It  should  be  remembered  that  zealous  admin- 
istrators may  not  have  proper  conception  of  the  scientific 


LAWS  AND  THEIR  RELATIONS  99 

facts  of  disease  nor  of  tlie  practical  problems  of  legitimate 
medical  practice  in  addiction-disease.  The  quality  of  the 
act  in  the  determination  of  legitimate  medical  practice 
is  often  if  not  as  a  rule  more  important  than  the  mere  act 
itseK.  There  has  been  as  yet,  so  far  as  I  know,  no  satis- 
factory legal  definition  of  legitimate  medical  practice. 
The  author  sees  no  reason  why  the  same  rules  and  criteria 
as  have  developed  or  are  formulated  for  legitimate  med- 
ical practice  in  other  diseases  might  not  be  applied  to  the 
treatment  of  addiction-disease.  In  a  general  way  the 
legitimate  practice  of  medicine  in  the  care  of,  handling 
of  or  treatment  of  a  disease  consists  of  such  medical  at- 
tention, advice,  instruction  and  guidance,  and  clinical 
or  therapeutic  ministrations  as  may  be  indicated  by  the 
needs  of  the  individual  case.  In  addiction-disease  if  a 
physician  proceeds  upon  the  physical,  clinical  and  other 
indications  exhibited  in  the  individual  case,  being  held 
responsible  for  reasonable  familiarity  with  such  indica- 
tions, and  fulfilling  to  the  best  of  his  available  equipment 
and  professional  ability  the  general  and  therapeutic  re- 
quirements of  each  case,  it  is  difficult  for  the  author  to  see 
how  he  can  be  held  to  be  engaged  in  illegitimate  practice. 
He  can  of  course  be  held  responsible  for  reasonable 
familiarity  with  available  teaching  and  information  on 
the  subject  treated  by  him,  and  for  average  intelligence 
and  honest  application  of  medical  principles  and  practice. 
It  seems  to  the  author  that  legitimate  practice  as  deter- 
mined in  other  diseases  would  go  a  long  way  towards  the 
elimination  of  the  charlatan  and  shyster  physician  and 
would  not  carry  with  it  the  menace  and  jeopardy  which 
technical  violation  of  often  medically  impractical  admin- 
istrative demands  may  involve.  If  the  honest  physician 
is  left  no  leeway  for  the  exercise  of  medical  judgment  in 
the  handling  of  widely  differing  cases  of  addiction-dis- 
ease, or  if  his  exercise  of  honest  clinical  judgment  is  to 
be  constantly  influenced  by  a  necessity  of  worrying  about 


100  THE  NARCOTIC  DRUG  PROBLEM 

its  possible  interpretation,  in  the  light  of  unduly  stringent 
laws  and  regulations,  a  condition  is  created  in  which  the 
intelligent  practice  of  medicine  upon  the  sufferer  from 
addiction-disease  becomes  impossible. 

A  matter  about  which  there  has  been  a  great  deal  of 
dispute  is  that  of  the  prescribing  or  dispensing  by  the 
practitioner  of  medicine  of  opiate  drugs  to  the  narcotic 
addict  in  the  handling  of  narcotic  addiction,  itself.  The 
adherents  of  the  older  theory  of  addiction  being  merely 
habit  or  vicious  indulgence,  oppose  as  illegitimate  practice 
the  continued  supply  of  the  opiate  to  an  addiction  patient, 
unless  in  some  oases  the  patient  also  suffers  from  some 
painful  and  incurable  disease. 

They  take  the  attitude  that,  if  the  addict  did  not  want 
to  keep  on  using  opiate  he  would  go  somewhere  and  be 
cured,  and  that  as  long  as  he  can  get  opiate  drug  he  will 
not  get  "  cured."  The  possibilities  of  immediate  so- 
called  "  cure "  are  discussed  elsewhere  in  this  volume. 
Sufficient  for  present  statement  is  the  fact  that,  as  demon- 
strated by  the  testimony  of  the  Whitney  Committee  Legis- 
lative Investigation  hearings,  one  of  the  most  complete  and 
valuable  pieces  of  public  investigation  work  into  addiction 
ever  done,  there  exists  at  present  practically  no  adequate 
or  competent  machinery  for  the  successful  so-called 
"  cure  "  of  the  great  numbers  of  narcotic  addicts.  This  is 
discussed  elsewhere.  Those  who  talk  casually  of  the  en- 
forced immediate  cure  of  the  narcotic  addict  would  do  well 
to  investigate  and  realize  the  lack  of  possibilities  of  itg 
immediate  attainment  on  any  large  scale.  This  is  a  basic 
fact  which  has  been  too  little  taken  into  account  by  those 
who  still  hold  to  the  appetite  and  habit  theories. 

In  the  narcotic  drug  situation  we  are  confronted  by 
fact  and  not  by  theory.  Intelligent  comprehension  and 
unbiased  investigation  are  needed  far  more  than  we  need 
premature  conclusions  drawn  from  insufficient  experience 
or  too  narrow  observation  along  special  lines.     The  funda- 


LAWS  AND  THEIR  RELATIONS  101 

mental  fact  is  this,  as  has  been  repeatedly  stated,  that 
the  narcotic  addict,  until  his  disease  mechanism  can  be 
competently  and  snccessfuUy  arrested  physically,  needs 
the  daily  administration  of  sufficient  quantities  of  the 
drug  of  his  addiction  to  meet  the  indications  of  his  dis- 
ease. If  the  drug  is  not  administered  to  him  in  sufficient 
amounts  to  meet  these  disease  indications,  he  cannot  be 
blamed  if,  in  the  agony  of  his  suffering  and  the  desperate- 
ness  of  his  plight,  he  is  forced  into  the  underworld  and 
the  illicit  channels  of  supply  for  the  continuance  of  a 
physically  endurable  and  economically  possible  existence. 
Until  the  medical  profession  and  the  medical  institutions 
—  hospital  and  otherwise  —  have  in  competent  execution 
methods  of  handling  and  treatment  of  the  narcotic  addict 
which  are  more  humane  and  more  effective  than  those 
shown  by  ample  testimony  to  be  in  common  use,  the  sup- 
ply of  narcotic  drug  to  the  responsible  narcotic  addict  to 
the  extent  of  physical  need,  without  unjustifiable  exploita- 
tion, financial  or  otherwise,  is  the  duty  of  the  medical 
man.  Any  law  which  to  this  extent  limits  the  supply  of 
opiate  drug  to  the  addict  should  receive  the  support  of 
the  medical  profession.  Any  law  which  renders  it  diffi- 
cult or  impossible  for  a  physician  to  conscientiously  and 
rationally  meet,  to  this  extent,  the  indications  of  narcotic 
drug  disease,  should  meet  from  the  medical  profession 
with  a  united  and  honest  attempt  at  its  modification. 

Above  all  there  should  be  fostered  and  promoted  by  the 
medical  profession  an  intelligent,  unbiased  investigation 
into  the  actual  facts  surrounding  the  problem  of  narcotic 
drug  addiction  as  a  definite  disease.  Such  information 
concerning  the  physical  and  clinical  facts  of  this  disease, 
as  we  should  be  in  a  position  to  give,  would  be  eagerly 
welcomed  by  the  law-makers  and  the  administrators  and 
the  judiciary;  and  we  should  be  in  a  position  to  co-op- 
erate with  them  in  the  making  and  interpreting  of  nar- 
cotic drug  laws.     Lack  of  such  information  h'as  played 


102         THE  NARCOTIC  DRUG  PROBLEM 

an  important  part  in  whatever  mistakes  our  police,  legis- 
lative and  administrative  bodies  have  made,  and  forced 
them  to  proceed  as  best  they  could  to  meet  the  demand 
of  a  public  menace  that  could  no  longer  be  denied. 

What  has  the  law  done  for  the  addict  ?  Like  the 
physicians,  the  legislators  have  done  the  best  they  could 
in  the  light  of  their  knowledge,  experience  and  teaching. 
Some  of  them  seem,  however,  to  have  had  their  attention 
directed  unduly  to  a  special  class  of  those  addicted,  the 
addicts  found  among  the  type  of  person  which  begins  or 
tends  to  end  among  the  criminal  or  vicious  of  the  so- 
called  "  underworld."  Legislators  and  administrators 
have  realized  that  the  taking  of  narcotic  drugs  was  rapidly 
spreading,  and  that  it  constituted  a  public  menace  in  the 
class  to  which  their  attention  was  directed;  and  they  ap- 
plied the  means  at  their  disposal  in  the  remedy  of  what 
they  saw.  But  again,  like  the  physician,  they  tended  to 
center  their  attention  upon  the  mere  taking  of  narcotic 
drug,  and  they  attempted  to  control  by  legislation  the 
possession  and  use  of  narcotic  drugs  with  too  little  ap- 
preciation of  fundamental  disease  facts  and  of  general 
basic  considerations  of  widespread  application.  They  did 
not  seem  to  have  appreciated  the  extent  to  which  their 
legislation  or  administration  would  affect  the  great  num- 
bers of  upright,  and  innocent  and  worthy  addiction-suf- 
ferers of  whom  they  did  not  know,  and  who  did  not 
possess  the  fundamental  characteristics  of  the  class  and 
type  of  person  addicted  against  which  they  legislated. 
They  rightly  directed  their  attention  towards  the  control 
of  the  sources  of  drug  supply  and  they  rightly  limited  the 
ultimate  legal  supplying  of  drug  to  duly  licensed  and 
responsible  persons  and  institutions,  specifically  described. 
The  slogan  of  most  of  the  special  legislation  has  been  to 
place  responsibility  for  the  supply  and  use  of  narcotic 
drugs  squarely  upon  the  shoulders  of  the  medical  profes- 
sion.    Such  effort  is  wise,  and  this  is  where  the  respon- 


LAWS  AND  THEIR  RELATIONS  103 

sibility  belongs.  And  this  is  wliere  the  medical  profes- 
sion would  have  it  placed  in  so  far  as  the  medical  pro- 
fession supplies  narcotic  drugs. 

The  honest  physician  has  no  desire  to  dodge  respon- 
sibility for  his  handling  of  narcotic  addicts  to  the  best 
of  his  ability,  nor  should  he  have  any  objection  to  a  rea- 
sonable responsibility  and  accounting  for  narcotic  drugs 
used  in  that  handling;  especially  since  the  taking  of  nar- 
cotic drugs  has  in  certain  of  its  phases,  developed  as  a 
serious  situation  entirely  outside  of  the  medical  profes- 
sion, in  v^hich  situation  these  drugs  are  non-professionally 
supplied  and  used  to  such  an  extent  as  to  constitute  a 
public  menace.  The  non-medical  supplying  and  admin- 
istering of  such  drugs  should  not,  however,  be  controlled  in 
such  a  way  as  to  unduly  hamper  their  honest  and  legiti- 
mate use  by  medical  men,  and  to  deprive  the  honest,  worthy 
and  innocent  sufferer  from  addiction-disease  of  their 
legitimate  therapeutic  administration. 

One  of  the  chief  and  most  serious  phases  of  the  nar- 
cotic drug  problem,  which  for  obvious  reasons  has  espe- 
cially called  for  legislation,  is  the  illicit  and  illegitimate 
commerce  in  narcotic  drugs.  The  class  of  addicts  which 
constitutes  a  public  menace  is  largely  so  supplied.  This 
fact  is  recognized  in  the  recent  report  of  the  Special  Com- 
mittee of  Investigation  Appointed  by  the  Secretary  of 
the  Treasury,  in  which  is  stated,  "  This  illegitimate  traffic 
has  developed  to  enormous  proportions  in  recent  years, 
and  is  a  serious  menace  at  the  present  time.  It  is  through 
these  channels  that  the  addict  of  the  underworld  now 
secures  the  bulk  of  his  supplies." 

This  Report  further  states  that  "  there  is  the  so-called 
'  underground  '  traffic  which  is  estimated  to  be  equal  in 
magnitude  to  that  carried  on  through  legitimate  channels. 
This  trade  is  in  the  hands  of  the  so-called  ^  Dope  ped- 
dlers,' who  appear  to  have  a  national  organization  for 
procuring  and  disposing  of  their  supplies.     For  the  most 


104         THE  NARCOTIC  DRUG  PROBLEM 

part  it  is  thought  that  they  obtain  their  supplies  by 
smuggling  them  from  Mexico  or  Canada,  although  smaller 
quantities  of  these  drugs  are  obtained  from  unscrupulous 
dealers  in  this  country  or  by  theft,"  etc.  There  should 
be  some  way  to  dissociate  entirely,  conclusively  and  finally 
in  the  minds  of  the  public  the  illegitimate  and  underworld 
traffic  in  narcotic  drugs  from  the  efforts  of  the  honest 
physician  to  practice  rational  and  scientific  medicine  in 
the  help  of  the  worthy  and  deserving  addict.  The  regu- 
lation of  the  narcotic  drug  traffic  of  the  underworld  or 
"  underground  "  is  not  the  business  of  the  medical  pro- 
fession, and  the  burden  of  responsibility  for  it  should  not 
be  placed  upon  the  shoulders  of  the  medical  profession  or 
the  consequences  of  it  made  to  react  upon  the  head  of 
the  honest  physician  and  innocent  addiction  sufferer. 
There  is  a  tremendous  number  of  excellent  and  worthy 
and  even  illustrious  people  in  whom  addiction  is  in  no 
way  associated  with  vice,  or  other  morbidity  of  mental  or 
environmental  origin,  who  are  merely,  solely  and  simply 
sick  people  suffering  from  addiction-disease,  whose  prob- 
lem is  the  control  of  that  disease  until  it  can  be  arrested 
by  competent  therapeutic  procedure,  for  which  they  con- 
stantly seek.  Misconception  of  them  and  neglect  of 
sufficient  consideration  of  them  is  the  tragic  aspect  of 
the  narcotic  drug  situation,  and  causes  tremendous  in- 
dividual and  economic  wastage.  They  do  not  in  any  way 
associate  with  underground  traffic  unless  or  until  driven 
to  it  by  failure  of  legitimate  sources  of  opiate  medication, 
or  by  the  surrounding  of  legitimate  sources  with  such 
restrictions  as  make  the  man  of  standing  and  reputation, 
afflicted  with  addiction-disease,  fear  possible  publicity  and 
economic  detriment. 

It  is  the  duty  of  the  medical  organizations  to  see  to  it 
that  these  deserving  purely  medical  problems  and  worthy 
sick  people  and  their  honest  medical  advisers  shall  no 
longer  than  avoidable  be  permitted  to  remain  confused 


LAWS  AND  THEIR  RELATIONS  105 

in  the  minds  of  the  laitj  and  of  the  medical  profession 
itself  with  the  problems  of  regulation  of  "  underground '' 
traffic  and  the  control  of  the  "  underworld ''  addict.  It  is 
the  duty  of  the  medical  organizations  also  to  see  to  it  that 
in  the  public  press  and  elsewhere,  and  especially  in  their 
own  scientific  journals,  the  acts  of  the  occasional  in- 
dividual with  medical  degree  who  prostitutes  his  medical 
standing  and  the  aims  and  ideals  of  his  profession  in  the 
commercial  exploitation  of  the  drug  addict  are  not  pre- 
sented in  such  a  way  as  to  cause  by  inference  or  otherwise, 
their  confusion  with  the  honest  efforts  of  honest  medical 
men  who  are  engaged  to  the  best  of  their  ability  in  the 
humane  and  ethical  help  of  the  deserving  sufferer  from 
addiction-disease. 

It  is,  furthermore,  the  duty  of  the  medical  organiza- 
tions to  see  to  it  that  whatever  laws  and  regulations  are 
promulgated  in  the  control  of  criminal  and  unworthy 
shall  not  be  framed  or  administered  in  such  a  way  as  to 
unnecessarily  jeopardize  the  reputation  and  liberties  of  the 
honest  practitioner  and  to  interfere  with  his  conscientious 
efforts  to  care  for  his  honest  and  innocent  addiction-dis- 
ease patients  to  such  an  extent  as  makes  that  care  impos- 
sible. 

Legislation  or  administrative  regulation  which  limits 
to  responsible  and  authorized  persons  possession  and  dis- 
tribution of  narcotic  drugs  and  which  compels  from  such 
persons  reasonable  accounting  for  such  possession  and  dis- 
tribution, is  under  conditions  which  have  long  existed  but 
only  recently  been  sufficiently  recognized  necessary  and 
desirable.  The  Harrison  Law  was  a  definite  response  to 
an  obvious  need,  in  its  obvious  intent  and  draughting  a 
wise  and  unobjectionable  legislation.  It  provided  for  re- 
sponsible possession  and  distribution  and  it  enforced  an 
accounting  for  the  same,  but  did  not  unwisely  restrict,  in 
its  text,  nor  hamper  the  legitimate  possession  and  honest 
therapeutic    employment    of    narcotic    drugs.     From    the 


106         THE  NARCOTIC  DRUG  PROBLEM 

medical  organizations  and  educational  and  scientific  in- 
stitutions should  be  available  scientific  study  and  under- 
standing of  narcotic  drug  addiction-disease  available  for 
tbe  information  of  conscientious  executives  and  adminis- 
trators, who  must  exercise  their  best  judgment  in  the 
light  of  available  and  prevailing  teaching.  It  is  the  duty 
of  the  medical  organizations  to  see  to  it  that  available  and 
prevailing  addiction-disease  information  and  teaching  is 
honest,  unbiased  and  competent. 

Those  who  are  responsible  for  our  laws  should  remem- 
ber that  the  possible  interpretation  and  administration  of 
the  laws  they  draught  are  very  important  considerations, 
and  determine  the  real  effect  of  the  laws  often  more  than 
does  the  intent  of  the  makers.  Legislation  which  is  un- 
duly stringent  or  is  capable  of  unduly  stringent  adminis- 
tration may  have  unfortunate  reaction  and  influence  upon 
honest  effort  in  the  care  of  the  deserving  sick.  Kestricting 
beyond  reasonable  limits  the  care  of  the  honest  narcotic 
drug  addict  simply  tends  to  make  it  impracticable  and 
dangerous  for  the  average  medical  man  to  have  anything 
to  do  with  narcotic  addicts,  and  to  drive  the  honest  and 
deserving  patient  into  (the  underworld,  into  the  insane 
asylum  or  to  suicide.  Until  we  have  provided  scientific 
and  clinical  study,  and  have  thoroughly  investigated  pres- 
ent and  possible  medical  treatment  and  handling  of  nar- 
cotic-drug addiction-disease,  and  have  established  humane 
and  effective  therapeutic  measures  and  procedures  in  the 
control  and  remedy  of  this  disease,  we  should  not  deprive 
the  majority  of  honest  addicts  of  the  only  medication  and 
means  by  which  they  can  at  present  remain  self-supporting 
citizens.  The  handling  of  the  problem  of  the  underworld 
and  of  underground  supply  is  not  going  to  be  solved  by 
too  restrictive  regulation  of  the  honest  physician.  Legis- 
lation or  regulation  which  makes  it  practically  impossible 
for  the  honest  physician  to  care  for  the  honest  case  of 


LAWS  AND  THEIR  RELATIONS  107 

addiction-disease  is  a  boon  to  charlatans,  and  medical 
shysters,  and  the  illicit  underworld  traflBc. 

It  is  the  opinion  of  some  that  the  handling  and  treat- 
ment of  narcotic  addiction  should  be  taken  out  of  the 
hands  of  the  practitioner  of  medicine.  The  statement  is 
made  that  the  practitioner  of  medicine  is  not  competent 
to  handle  a  case  of  this  disease.  It  has  been  advised  that 
the  treatment  of  narcotic  addicts  should  be  restricted  to  a 
small  number  of  specially  designated  and  licensed  men  and 
institutions.  How  and  by  whom  are  those  special  men 
and  institutions  to  be  selected?  In  the  present  state  of 
chaotic  and  widely  diversified  medical  and  lay  opinion 
as  to  narcotic  addiction  and  the  narcotic  addict  it  would 
be  a  very  difficult  matter  to  select  the  men  or  the  institu- 
tions for  such  absolute  control.  The  comprehension, 
study  and  investigation  of  narcotic  drug  addiction  has  en- 
tered a  stage  of  evolution  and  development  in  which  new 
facts  and  new  truths  —  both  as  to  the  addict  and  as  to 
the  condition  from  which  he  suffers  —  are  being  recognized 
and  must  be  threshed  out,  correlated  and  coordinated  with 
hitherto  existing  opinion  before  too  restrictive  measures 
will  be  anything  but  narrow-visioned,  premature  and 
harmful. 

There  are  undoubtedly  institutions,  many  of  them  not 
widely  known,  in  which  is  available  skilKul,  humane,  in- 
telligent and  successful  handling  of  this  disease.  From 
personal  observation  and  experience  in  institutional  work, 
and  from  analysis  and  investigation  of  many  histories, 
it  is  my  opinion  that  the  results  of  institutional  treatment 
depend  more  upon  the  quality  of  its  medical  and  nursing 
staff  than  upon  any  other  consideration.  That  the  mere 
fact  that  addiction-disease  is  handled  in  an  institution 
is  a  very  minor  consideration  in  comparison  with  the  in- 
telligence of  that  handling,  is  amply  attested  to  in  the 
testimony  of  the  Whitney  Hearings  and  by  the  experience 
of  many  addicts.     Unquestionably,   unknown  and  large 


108         THE  NARCOTIC  DRUG  PROBLEM 

numbers  of  narcotic  addicts  have  been  relieved  of  their 
addiction  in  reputable  sanitaria  conducted  by  skillful  and 
competent  medical  men.  Also  unquestionably,  large 
numbers  of  addicts  have  been  relieved  of  their  addiction 
through  the  honest  efforts  of  practitioners  of  medicine, 
in  private  practice.  Unfortunately  these  efforts  and  their 
results  have  received  entirely  too  little  recognition. 

The  average  physician  may  be  inexpert  and  not  as  com- 
pletely educated  in  the  appreciation,  understanding  and 
clinical  handling  of  narcotic  drug  addiction-disease  as  he 
is  in  other  diseases.  The  common-sense  remedy  for  this 
situation,  however,  is  not  to  drive  the  addict  out  of  his 
hands,  but  to  make  him  as  competent  in  that  addict's 
handling  as  he  is  in  any  other  clinical  condition.  It  is 
only  a  matter  of  time  and  education  before  the  competent 
practitioner  of  internal  medicine  can  be  brought  to  a  com- 
prehension of  and  ability  to  intelligently  handle  addiction- 
disease.  It  is  largely  a  matter  of  securing  general  ap- 
preciation of  and  ability  to  clinically  recognize,  and  in- 
terpret physical  symptomatology,  and  to  meet  the  indica- 
tions of  individual  disease  manifestations. 

The  ultimate  solution  of  the  problem  of  handling  the 
narcotic  addict  lies  largely  in  the  education  of  medical 
men,  both  in  institutions  and  in  private  practice,  and 
through  them  securing  lay  appreciation  of  disease  facts. 
Any  legal  or  administrative  restrictions  which  drive  the 
care  of  the  honest  addict  out  of  the  hands  of  the  honest 
medical  man  simply  postpone  the  day  when  this  ideal 
may  be  consummated. 

Some  addicts,  as  individuals  and  tiv'pes,  will  of  course 
always  require  institutional  and  custodial  handling.  The 
handling  of  the  addict  who  is  criminal  or  vicious  belongs 
within  the  province  of  the  penological  authorities,  just  as 
does  the  handling  of  any  other  man  who  is  criminal  or 
vicious.  The  handling  of  the  addict  who  is  fundamentally 
degenerate,  defective  or  mentally  weak  may  require  the 


LAWS  AND  THEIR  RELATIONS  109 

attention  of  the  alienist  and  institutional  restraint,  just 
as  may  the  handling  of  any  other  man  who  is  degenerate 
or  defective.  ^N^arcotic  drug  addiction-disease  in  the  man 
who  is  vicious  or  criminal  or  defective  or  degenerate 
should  be  treated  as  narcotic  drug  addiction-disease,  as  any 
other  disease  is  treated  in  the  same  individual. 

To  our  legislators  and  administrators  and  forces  of 
penology,  custody  and  correction  rightfully  belongs  the 
problem  of  looking  after  the  criminal  and  vicious  addict 
as  well  as  providing  for  the  eradication  of  illicit,  irre- 
sponsible, and  ^^  underground  "  traffic  in  narcotic  drugs. 
If  the  illicit  trafficker  happens  to  be  a  physician  he  should 
have  no  more  consideration  at  the  hands  of  the  law  than 
any  other  criminal  and  in  its  action  the  law  should  have 
complete  co-operation  of  the  medical  profession,  which 
should  see  to  it  also  that  conscientious  endeavor  of  its 
honest  members  is  not  confused  in  its  consideration  with 
illicit  traffic  and  that  the  acts  of  the  doctor  shall  be  de- 
termined and  estimated  upon  broad  principles  of  medical 
practice  and  not  upon  violation  of  incidental  technicalities. 
Great  care  should  be  taken  that  the  sins  of  a  guilty  few 
are  not  visited  upon  the  heads  of  a  deserving  many. 

Until  there  is  available  competent  and  adequate  med- 
ical care  for  the  honest  narcotic  addict  sufficient  in  extent 
to  meet  the  needs  of  the  thousands  of  sufferers,  and  en- 
couragement and  protection  as  well  as  restriction  is 
afforded  to  the  honest  physician,  the  illicit  traffic  will  con- 
tinue and  grow,  including  in  its  toils  many  who  would 
not  otherwise  seek  it.  Before  we  have  further  medical 
restrictions,  we  should  have  both  medical  and  lay  and 
official  education.  Over-emphasis  on  any  aspect  result- 
ing in  premature,  narrow,  ill-considered  and  ill-advised  ac- 
tion only  increases  the  complexity  of  the  situation  and 
defers  final  remedy.  Por  as  great  and  complicated  a 
problem  as  narcotic  drug  addiction  there  will  be  found 
no  special  or  specific  panacea. 


110         THE  NARCOTIC  DRUG  PROBLEM 

In  conclusion  I  feel  that  a  great  deal  more  thought  and 
attention  should  be  paid  to  the  testimony  of  the  public 
hearings  of  the  ^ew  York  Legislative  Investigating  Com- 
mittee, under  the  leadership  of  Senator  George  H.  Whit- 
ney, Chairman  of  the  Committee.  A  vast  amount  of 
valuable  data  was  produced.  It  showed  for  the  first  time 
to  my  knowledge  an  official  effort  to  secure  the  true  story 
of  the  narcotic  addict  in  all  of  its  applications  and  cir- 
cumstances. It  is  significant  that  the  Preliminary  Re- 
port of  the  Whjtney  Committee  gave  official  recognition 
of  the  fact  thaf  narcotic  drug  addiction  is  a  physical  dis- 
ease. So  important  and  enlightening  was  the  above  men- 
tioned report,  that  it  is  deemed  desirable  to  quote  from 
it  in  part  as  follows : 

"  Lack  of  understanding  and  appreciation  of  the  dis- 
ease of  narcotic  drug  addiction  and  its  treatment  by  a 
large  majority  of  the  medical  profession  has  fostered  con- 
ditions which  make  it  impossible  to  determine  a  rational 
procedure  for  treating  and  curing  the  addicted  by  the 
State  at  this  time. 

^^  Such  absence  of  uniformity  of  opinion  has  worked 
great  hardship  upon  the  public  and  has  laid  the  narcotic 
drug  addict  open  to  misconception,  misunderstanding  and 
medical  treatment  which,  in  many  instances,  has  resulted 
in  harm  rather  than  good. 

"  Evidence  offered  by  physicians  shows  that  many 
addicts  have  died  under  the  methods  of  treatment  existing 
to-day  and  that  a  large  percentage  of  those  discharged 
from  institutions  as  '  cured '  are  driven  back  to  use  of 
narcotics  through  unbearable  physical  torture  induced  by 
improper  withdrawal  of  their  drug. 

"  Evidence  from  physicians  was  adduced  which  denied 
that  any  cure  for  narcotic  drug  addiction  existed  in  any 
of  the  private  or  public  institutions  of  this  State.  Evi- 
dence from  other  eminent  physicians  was  adduced  which 


LAWS  AND  THEIR  RELATIONS  111 

bore  testimony  to  the  fact  that  the  disease  of  narcotic 
drug  addiction  was  curable.  *.'--  ^m^  /*^V^,, . 

"  The  difference  of  medical  opinion  existing  in  medical 
circles  regarding  this  vitally  important  question  should 
be  made  the  subject  of  a  thorough  and  searching  investi- 
gation as  a  matter  of  the  greatest  importance  to  the  wel- 
fare of  a  large  number  of  people  in  the  State  of  E'ew 
York. 

"  Your  Committee  has  found  that  narcotic  drug  addic- 
tion bears  no  relation  in  point  of  character  and  serious- 
ness to  any  other  known  habit  induced  by  the  use  of  stim- 
ulants. ISTarcotic  drug  addicts,  according  to  evidence 
adduced,  should  not  be  classed  with  the  alcoholic  or  the 
tobacco  addict  or  the  cocaine  habitue. 

"  The  constant  use  of  narcotics  produces  a  condition-^ 
in  the  human  body  that  many  physicians  of  medical  au- 
thority now  recognize  as  a  definite  disease,  which  diseased 
condition  absolutely  requires  a  continued  administration 
of  narcotics  to  keep  the  body  in  normal  function  unless 
proper  treatment  and  cure  is  provided. 

"  Withdrawal  of  the  drug  of  addiction  induces  such 
fundamental  physical  disorganization  and  unbearable  pain 
that  addicts  are  driven  to  any  extreme  to  obtain  narcotic 
drugs  and  allay  their  suffering  by  seK-administration. 

^^  Testimony  of  physicians  coming  in  contact  with  the 
addicts  and  statements  of  addicts  themselves  show  that 
those  afflicted  with  this  disease  express  every  desire  to 
secure  humane  and  competent  treatment  and  cure  and 
that  most  narcotic  drug  users  are  willing  to  undergo 
physical  torture  and  often  do  voluntarily  undergo  such 
torture,  in  an  effort  to  be  rid  of  their  so-called  habit. 

^^  In  the  present  chaotic  condition  of  medical  opinion^, 
on  this  subject,  it  is  impossible  for  the  addict  to-day  to    | 
either  secure  authentic  information  on  the  subject  of  his 
disease  and  its  treatment,  or  to  procure  at  the  hands  of 


112         THE  NARCOTIC  DRUG  PROBLEM 

the  average  physician  competent  treatment  for  his  malady. 
^  "  It  has  further  been  stated  by  competent  authorities 
before  your  Committee  that  drug  addiction  is  not  con- 
fined to  the  criminal  or  defective  class  of  humanity. 

^^  This  disease,  however  contracted,  is  prevalent  among 
members  of  every  social  class.  Some  physicians  estimate 
that  addicts  of  the  so-called  underworld  are  far  out-num- 
bered by  unfortunate  drug  users  drafted  from  social 
circles  of  refinement  and  intelligence  in  the  State  of  'New 
York,  who  have  become  addicted  to  the  constant  use  of 
narcotic  drugs,  but  who  are  able  to  hide  their  affliction 
from  the  public. 

"  The  attitude  of  the  public  toward  the  narcotic  drug 
,  addict,  fostered  by  the  increasing  prevalence  of  the  dis- 
ease in  the  criminal  classes  and  by  the  apparent  lack  of 
medical  help,  has  forced  such  drug  users  to  keep  their 
affliction  a  secret. 

'^  This  necessity  in  turn,  your  Committee  finds,  has  ap- 
parently contributed  to  the  existence  of  many  unsound 
nostrums  for  the  cure  of  narcotic  drug  addiction  and  many 
private  institutions  where  this  disease  is  purported  to  be 
cured  which  exist  solely  for  the  purpose  of  preying  upon 
the  addict. 

^'  State  investigation  and  regulation  of  such  cures  and 
institutions  is  recommended  by  your  Committee. 

"  Your  Committee  is  inclined  to  criticize  the  medical 
profession  for  its  lack  of  study  of  the  increasingly  im- 
portant subject  of  narcotic  drug  addiction.  The  only 
excuse  which  can  be  offered  for  this  unfortunate  condi- 
tion lies  in  the  fact  that  there  has  not  been  medical  ap- 
preciation of  conditions  and  that  legislation,  both  State 
and  Federal,  has  forced  upon  the  physician  a  situation 
for  which  he  was  wholly  unprepared. 

"  The  testimony  taken  by  your  Committee  shows  that 
those  charged  with  the  sale  and  distribution  of  narcotic 
drugs  are  in  the  main  observing  the  law,  and  that  the 


LAWS  AND  THEIR  RELATIONS  113 

legal  distribution  of  these  drugs  is  less  than  before  the 
enactment  of  existing  narcotic  laws.  Federal  and  State. 

"  On  the  other  hand  it  is  apparent  from  this  testimony 
that  public  consumption  of  narcotic  drugs  has  increased 
to  an  alarming  extent.  The  inevitable  conclusion  is  that 
the  unfortunate  addict  has  been  forced  to  and  does  obtain 
his  supply  illegally. 

"  This  condition  arises  very  largely  from  the  fact  that 
many  physicians  and  pharmacists,  either  through  misun- 
derstanding of  the  law  or  the  true  nature  of  the  addict's 
disease,  have  refused  to  prescribe  or  dispense  narcotic 
drugs  to  the  sufferer. 

"  Your  Committee  contends  that  any  member  of  the 
medical  or  pharmaceutical  professions  who  refuses  either 
to  prescribe  or  to  dispense  narcotic  drugs  to  the  honest 
addict  to  alleviate  the  suffering  and  pain  occasioned  by 
lack  of  narcotics  is  not  living  up  to  the  high  standards  of 
humanity  and  intelligence  established  by  these  great  pro- 
fessions." 


CHAPTER  IX 

SOME.    COMMETsTTS    UPON    THE    LBGITIMATE    USE'  OF 
NAUCOTIOS    IN    PEACE    AND    WAE 

Before  commentiiig  upon  the  legitimate  use  of  nar- 
cotics, it  is  desirable  to  emphasize  again  that  the  term 
^'  narcotics  "  as  used  in  this  volume  refers  particularly  to 
the  preparations  and  derivatives  of  opium,  because  as 
the  term  ^^  narcotics  "  has  come  to  be  used  it  is  synony- 
mous in  the  minds  of  many  with  "  habit-forming  drugs,''  a 
phrase  often  loosely  used  and  grouping  under  its  title  a 
number  of  drugs  of  widely  dissimilar  action  and  proper- 
ties. 

Although  many  of  these  drugs  have  narcotic  properties, 
their  action  upon  the  human  body  is  in  many  respects 
totally  unlike  the  action  of  the  opiates  themselves.  Also 
the  condition  resulting  from  their  prolonged  and  con- 
tinuous administration  is  an  entirely  different  condition 
clinically  and  physiologically  from  that  manifested  in  the 
case  of  opiate  addiction-disease.  The  problems  associated 
with  the  use  of  alcohol,  cocaine,  chloral,  cannabis,  the 
various  coal  tars,  etc.,  differ  from  each  other  and  all  of 
them  are,  in  their  basic  medical  principles,  of  an  entirely 
different  character  from  the  problems  associated  with  the 
use  of  opiates.  As  has  been  previously  stated,  it  has  not 
yet  been  demonstrated  that  any  of  them  form  the  basis 
for  an  addiction-disease  mechanism  such  as  clinical  study 
and  laboratory  experiment  seem  to  demonstrate  in  opiate 
addiction-disease. 

In  considering  legitimate  as  well  as   illegitimate  use 

of  opiates,  therefore,  it  is  important  not  to  confuse  them 

114 


LEGITIMATE  USE  OF  NARCOTICS        115 

witH  tlie  drugs  above  mentioned  and  to  be  sure  that  in 
the  mind  of  the  reader  there  shall  not  exist  any  lingering 
impression  that  attributes  popularly  supposed  to  be  as- 
sociated with  so-called  "  habit-forming  drugs "  are  of 
necessity  displayed  in  the  opiate  group. 

The  habitual  use  of  cocaine  for  example,  may  be  re- 
garded as  an  indulgence  of  appetite  and  the  obtaining  of 
sensation  and  artificial  stimulation  and  not  as  based  upon 
the  demands  of  a  specific  physical  addiction-disease 
mechanism.  The  therapeutics  of  its  discontinuance  are 
entirely  different.  Habitual  indulgence  in  cocaine  tends 
to  result  in  mental  and  moral  deterioration.  In  the  addict 
of  the  so-called  "  underworld  "  it  is  the  coincident  use  of 
cocaine  with  its  manifestations  of  mental,  moral  and 
physical  deterioration  that  has  led  to  the  wide  and 
erroneous  attributing  of  characteristics  of  this  class  of 
cocaine  habituates  to  the  average  opiate  addict.  The 
habitual  use  of  cocaine  is  an  entirely  different  matter 
from  the  continued  administration  of  opiate  in  the  case  of 
an  opiate  addict,  and  its  manifestations  should  be  com- 
pletely dissociated  from  the  clinical  picture  and  problem 
of  opiate  addiction-disease. 

Some  writers,  especially  those  associated  with  municipal 
or  state  institutions  of  penology  and  correction,  lay  em- 
phasis upon  the  case  of  the  so-called  "  mixed  addict." 
The  crimes  of  violence  with  which  addiction  has  become 
associated  in  the  popular  mind  are  practically  never  con- 
nected with  the  action  of  opiate  drug.  They  are,  however, 
characteristic  of  the  cocaine  crazed  individual.  When 
they  are  performed  by  a  so-called  ^^  mixed  addict "  they 
are  the  result  of  cocaine  habituation  rather  than  of  opiate 
addiction.  Such  crimes  of  violence  as  are  committed  by 
the  opium  or  morphine  addict  are  well  explained  in  the 
Report  of  the  Treasury  Investigation  Committee  in  the 
following  words,  "  There  are  many  instances  of  cases 
where  victims  of  this  disease  were  among  people  of  the 


116         THE  NARCOTIC  DRUG  PROBLEM 

highest  qualities  morally  and  intellectually,  and  of  the 
greatest  value  to  their  communities,  who,  when  driven  hy 
sudden  deprivation  of  their  drug,  have  been  led  to  com- 
mit felony  or  violence  to  relieve  their  misery." 

This  erroneous  grouping  of  so-called  "  habit  forming 
drugs  "  is  to  some  extent  responsible  for  a  misconception 
of  opiates  and  of  opiate  use  and  opiate  result  to  such  an 
extent  that  there  is  unfortunately  manifested  at  times  a 
lack  of  appreciation  of  the  very  important  legitimate  uses 
of  these  drugs. 

The  paramount  issue  of  legitimate  narcotic  medication 
is  that  of  the  opiates.  Opiates  form  and  must  continue 
to  form  the  most  indispensable  medication,  emergency  and 
otherwise,  for  shock,  wounds  and  allied  conditions.  It 
^  may  be  safely  stated  that  of  all  emergency  medication, 
the  opiates  would  be  the  last  to  be  surrendered  by  the  in- 
telligent physician  or  surgeon.  This  is  true  of  every  day 
civil  practice  and  its  importance  is  increased  tremendously 
under  conditions  of  active  warfare. 

The  opiates  possess  combined  actions  and  powers  not 
found  in  any  other  group  of  drugs.  In  therapeutic  doses 
they  support  the  heart  and  circulation,  they  relieve  pain, 
they  hold  in  check  excessive  activity  of  the  glands  of 
internal  secretion  with  all  their  associated  phenomena  of 
exhaustion  and  collapse ;  they  control  spasm  and  they  give 
sleep.  In  no  other  drugs  or  group  of  drugs  are  these 
properties  combined  as  they  are  in  the  opiate  group.  In 
emergency  medication,  opium  and  its  alkaloids,  especially 
morphine,  are  the  medications  often  most  responsible  for 
the  saving  of  life  and  reason.  It  is  not  necessary  to  argue 
this  point  with  any  intelligent  physician  or  surgeon.  Eor 
the  benefit  of  the  laity,  however,  and  for  the  benefit  of 
the  occasional  fanatic  and  hysterical  reformer  it  is  well 
to  state  that  without  the  use  of  morphine  and  other  opiates 
the  mortality  among  the  sick  and  wounded  would  be  vastly 
greater,  and  many  of  those  who  might  survive  in  spite 


LEGITIMATE  USE  OF  NARCOTICS        117 

of  its  non-administration  to  tliem  would  bear  for  the  rest 
of  their  lives  physical  and  mental  and  nerve  consequences 
of  gravest  character.  The  lives  and  minds  that  have  been 
saved  by  the  timely  administration  of  an  opiate  drug  are 
incalculable.  One  has  only  to  talk  with  those  who  have 
worked  under  the  stern  necessities  and  emergency  condi- 
tions of  warfare  to  appreciate  this  fact.  There  is  no 
known  drug  which  will  replace  clinically  and  therapeut- 
ically the  opiate  group.  At  present  it  is  as  indispensable 
in  meeting  emergency  indications  as  is  the  scalpel  of  the 
surgeon. 

It  would  be  entirely  unnecessary  to  discuss  or  to  ap- 
parently defend  the  use  of  narcotics  in  peace  as  well  as  in 
war-time  medication  if  it  were  not  for  the  fact  of  recent 
recognition  of  the  wide  existence  of  opiate  addiction  in 
the  civilized  world.  Combined  with  this  is  the  belief, 
often  met,  that  as  a  result  of  prolonged  opiate  adminis- 
tration, a  certain  proportion  of  soldiers  have  developed 
this  condition.  If  the  facts  of  addiction-disease  were 
widely  known  and  applied  to  its  proper  handling  and 
remedy,  there  should  be  no  hysteria  concerning  and  no 
criticism  against  legitimate  opiate  medication ;  even  if  un- 
avoidably continued  to  the  point  of  creating  this  condi- 
tion. That  opiate-addiction  is  one  of  the  medical  prob- 
lems of  war  is  recognized  and  must  be  openly  met.  In 
many  cases^  just  as  in  private  civil  practice,  the  physician 
is  confronted  by  a  choice  of  evils.  To  save  life  or  rea- 
son he  must  continue  opiate  medication  even  into  and 
past  the  danger  zone  of  beginning  opiate  addiction.  Lack 
of  popular  recognition,  appreciation  and  comprehension  of 
this  fact,  in  the  present  status  of  narcotic  addiction,  con- 
tains grave  dangers  of  hysteria  and  of  undeserved  and 
irresponsible  criticism.  That  this  criticism  is  based  on 
ignorance  makes  it  none  the  less  unpleasant  and  hamper- 
ing to  efficient  service. 

It  should  be  at  once  and  widely  taught  that  the  cases 


118         THE  NARCOTIC  DRUG  PROBLEM 

of  opiate  addiction  tliat  follow  war  time  administration 
of  opiate  do  not  constitute  a  new  medical  problem,  but 
simply  constitute  additional  cases  of  a  disease  wbich  has 
existed  insufficiently  appreciated  in  this  country  for  over 
half  a  century.  When  the  conditions  under  which 
wounded  and  sick  must  be  handled  in  the  emergencies  of 
war,  and  the  higher  percentage  of  urgent  and  severe  cases 
are  taken  into  account,  it  will  be  found  that  the  propor- 
tion of  wounded  and  sick  soldiers  with  this  addiction-dis- 
ease is  no  greater  and  is  very  probably  not  so  great  as  the 
proportion  of  people  in  civil  life  and  practice  who  have 
in  the  past  contracted  this  disease,  and  are  even  at  pres- 
ent contracting  it  as  a  result  of  opiate  medication,  un- 
avoidably or  otherwise  continued  to  the  point  of  addiction. 

As  the  facts  of  addiction-disease  development  as  a  re- 
sult of  unavoidable  military  therapeutics  become  known 
it  will  be  well  to  remember  that  the  conditions  are  no  dif- 
ferent in  character  and  exist  in  no  greater  relative  propor- 
tion than  the  same  conditions  in  civil  life  and  practice. 
The  principal  difference  .lies  in  the  greater  opportunity 
for  early  recognition. 

As  to  the  illegitimate  or  non-therapeutic  contraction  of 
addiction  within  the  army,  its  dangers  are  no  greater  and 
possibly  not  as  great  as  in  civil  life.  Some  non-medical 
cases  of  addiction  may  have  developed  within  the  ranks 
of  the  army.  It  may  be  said  of  them,  however,  that  army 
life  and  activity  and  training  probably  saved  many  more 
or  less  idle  and  ignorant  youths  imbued  with  a  spirit  of 
curiosity,  and  with  lack  of  normal  outlet  for  physical  and 
nervous  surplus  energies,  from  the  associations  and  en- 
vironments which  have  been  taken  advantage  of  by  those 
associated  with  illicit  commerce  in  the  creation  of  the 
addict  of  non-medical  origin,  which  has  so  increased  in 
the  past  four  or  five  years. 

It  is  my  belief  that  the  gathering  together  of  young 
men  presents   an  opportunity  for  the  education   of  the 


LEGITIMATE  USE  OF  NARCOTICS        119 

youtli  as  to  the  physical  and  disease  facts  of  opiate  ad- 
diction which  should  be  of  incalculable  benefit  in  the  solu- 
tion of  the  narcotic  problem  and  in  the  suppression  and 
prevention  of  "  underground "  and  underworld  narcotic 
traffic. 

The  foregoing  opens  to  discussion  another  legitimate 
use  of  narcotics.  This  use  is  the  intelligent  administra- 
tion of  opiate  in  the  control  and  therapeutic  handling  of 
whatever  cases  of  addiction  are  found  to  exist.  The  sit- 
uation within  the  army  as  regards  addiction  is  in  the  gen- 
eral indications  for  its  handling,  identical  with  the  situa- 
tion existing  in  civil  life.  The  man  who  has  fully  de- 
veloped opiate  addiction-disease  will  have  to  have  his 
opiate  supplied  to  him  intelligently  and  with  proper  ap- 
preciation of  the  symptomatology  and  reactions  of  addic- 
tion-disease until  there  is  equipment  and  educated  per- 
sonnel provided  for  his  intelligent  and  competent  hand- 
ling. Under  any  other  immediate  arrangements,  the 
addicted  soldier,  just  as  the  addicted  civilian,  will  in  his 
desperation  and  physical  torments  of  bodily  need  for 
opiate  drug,  endeavor  to  smuggle,  steal  or  otherwise  ob- 
tain in  any  way  possible  this  medication. 

In  brief  then,  and  to  recapitulate,  the  legitimate  use 
of  narcotics  will  be  roughly  divided  under  two  broad 
heads.  The  first  is  the  necessary  administration  of  opiate 
to  those  who  are  not  addicted  for  the  control  of  emergency 
or  other  indication  v^ith  which  every  competent  physician 
or  surgeon  is  familiar.  To  use  opiate  as  indicated  in 
such  cases  is  not  only  legitimate,  but  failure  to  use  it 
would  be  inhuman  and  barbarous  and  result  in  the  loss 
of  many  lives  and  in  the  making  of  wrecks  of  many  others. 
The  second  is  the  administration  of  opiates  to  those  un- 
fortunates, who  either  through  their  own  ignorance  or  j^ 
carelessness,  or  through  unavoidably  or  otherwise  pro- 
longed legitimate  or  necessary  medication  have  developed 
in  their  body  the  condition  of  opiate   addiction-disease, 


120         THE  NARCOTIC  DRUG  PROBLEM 

until  sucli  time  as  their  disease  can  be  arrested  by  com- 
petent medical  care  of  their  addiction-disease  mechanism. 

As  to  addiction  created  in  war  time,  there  is  consider- 
able amount  of  information.  This  is  not  the  time  nor  the 
place  for  detailed  discussion  of  that  information.  Calm 
consideration  of  it  should,  however,  suffice  to  still  the  voice 
of  any  objections  and  irrefutably  answer  arguments 
criticizing  existence  of  war-time  addiction.  The  greatly 
lacking  and  needed  element  in  its  consideration  and  hand- 
ling is  appreciation  of  it  as  physical,  controllable  and 
arrestable  disease.  The  laity  and  the  mothers  and  other 
relatives  and  the  friends  of  those  in  the  Army  and  Navy 
will  not  exhibit  panic  and  fear  once  the  intangible  horror 
and  vague  and  morbid  and  erroneous  picture  of  the  ^'  dope 
fiend  "  is  in  its  application  to  opiate  addiction  erased  from 
popular  conception  and  replaced  by  comprehension  of  a 
definite  physical  disease  clinically  controllable  and  in 
most  cases  therapeutically  remediable. 

To  what  extent  narcotic  drug  addiction-disease  will  prove 
to  be  a  medical  sequela  of  war  and  of  necessary  war- 
time medication  may  never  be  made  a  matter  of  accurate 
statistics.  The  popular  and  prevailing  attitudes  towards 
and  conception  of  the  condition  and  of  its  possessor  tend 
to  influence  towards  desperate  concealment  rather  than  to 
encourage  self-revelation.  As  has  been  stated  before  ad- 
diction-disease followed  the  Civil  War,  occasional  cases 
recently  existing  and  possibly  still  existing  among  the 
few  remaining  veterans  of  that  struggle,  addiction  dating 
back  to  Civil  War  medication.  The  Spanish  War  and 
necessary  medication  added  to  the  list  of  war-time  con- 
tracted addiction-disease.  Of  addiction  among  those 
participating  in  the  last  war,  it  is  at  present  wise  to 
simply  recognize  the  condition,  and  to  hope  that  as  the 
addiction-disease  sufferer,  developed  through  necessary 
war-time  medication  becomes  known,  he  will  not  have  to 


LEGITIMATE  USE  OF  NARCOTICS        121 

carry  tlie  addiction  stigma  of  past  attitudes  and  concep- 
tions, and  that  we  shall  be  in  a  position  to  accord  him 
intelligent  and  humane  consideration  and  handling  as  a 
deserving  sick  man,  whose  disease  was  contracted  in  our 
defense. 


ktca<.  i^^ 


CHAPTER  X 

GEITEEAL    SURVEY    OF    THE    SITUATION    AND    THE    NEED 

OF    THE    HOUK 

Fbom  the  foregoing  it  is  easy  to  see  that  the  sooner  the 
established  facts  of  the  fundamental  physical  basis  and 
reactions  of  the  addiction-states  become  matters  of  med- 
ical, sociological,  administrative,  and  lay  knowledge,  the 
earlier  there  will  be  a  rational  and  practical  consideration 
of  the  use  as  well  as  of  the  abuse  of  narcotic  drugs,  and 
a  beginning  of  solution  of  the  narcotic  drug  problem. 

Lack  of  knowledge  of  the  fundamental  and  constant 
physical  reactions  and  phenomena,  and  of  the  characteris- 
tic clinical  manifestations  of  this  disease,  and  of  the 
physical  suffering  of  drug  deprivation  is  in  a  very  large 
measure  responsible  for  failure  in  its  therapeutic  hand- 
ling in  the  past,  and  indirectly  responsible  for  whatever 
is  unjust  and  misdirected  in  the  framing  of  the  various 
laws,  and  also  for  a  great  part  of  whatever  incompetency 
and  lack  of  wisdom  has  appeared  in  their  administration. 

Lack  of  knowledge  of  the  disease  facts  of  narcotic  ad- 
diction is  also  responsible  for  the  practical  absence  of 
widespread  provision  for  humane  and  intelligent  handling, 
for  much  of  the  jeopardy  and  fear  on  the  part  of  the 
medical  practitioner  towards  these  cases,  and  for  the  ex- 
istence of  conditions  resulting  in  the  rapid  growth  and  in- 
crease of  the  worst  evils  of  the  present  situation. 

The  worst  evils  of  the  narcotic  drug  situation  are  not, 

as  is  widely  taught,  rooted  in  the  inherent  depravity  and 

moral  weakness  of  those  addicted.     They  find  their  origin 

in  opportunity,  created  bv  ignorance,   neglect  and  fear, 

'  122 


GENERAL  SURVEY  123 

for  commercial  and  other  exploitation  of  tlie  physical  suf- 
fering resulting  from  denial  of  narcotic  drug  to  one  ad^ 
dieted.  The  many  widely  advertised  drug  cures  derive 
their  prosperity  from  the  desperate  desire  of  the  narcotic 
addict  to  be  cured  of  the  condition  which  may  at  any 
time  cause  him  intense  physical  suffering.  The  worst 
evil  of  the  narcotic  situation  in  the  past  few  years,  and 
especially  since  the  enforcement  of  restrictive  legislation, 
without  provision  for  complete  investigation  of  the  whole 
situation,  for  education,  and  adequate  treatment  of  dis- 
ease aspects,  is  the  rapid  growth  and  spread  of  criminal 
and  underworld  and  illicit  traffic  in  narcotic  drugs.  This 
exists  to  its  present  extent  because  conditions  have  been 
created  which  make  smuggling  and  street  peddling  and 
criminal  and  illicit  traffic  tremendously  profitable,  and  it 
would  not  exist  to  its  present  extent  otherwise.  It  is 
simply  and  plainly  the  exploitation  of  human  suffering 
by  the  supplying  to  desperate  and  diseased  individuals,  at 
any  price  which  may  be  demanded,  one  of  the  necessities 
of  their  immediate  existence. 

Such  exploitation  would  become  unprofitable  on  any 
large  scale  if  the  disease  created  by  continued  adminis-  , 
tration  of  opiates  were  recognized  as   it  exists   and  its  / 
physical  demands  comprehended  and  provided  for  in  more 
legitimate  and  less  objectionable  ways. 

One  of  the  most  important  and  immediately  available  of 
these  ways  is  the  honest  practitioner  of  medicine.  If  the 
average  practitioner  of  medicine  were  made  familiar  with 
the  physical  facts  of  addiction-disease,  and  its  phenomena 
and  reactions,  and  were  encouraged  by  both  legal  and 
medical  authoritative  support  to  admit  addiction-disease 
patients  to  his  practice,  to  be  cared  for  just  as  other 
patients  to  the  best  of  his  honest  therapeutic  ability  and 
judgment  —  if  he  were  taught  to  regard  them  as  sick 
people  whom  he  could  help  —  if  he  were  relieved  of  uncer- 
tainty as  to  the  meaning  and  possible  interpretation  of 


lU         THE  NARCOTIC  DRUG  PROBLEM 

laws  and  reflations,  and  as  to  tlie  possible  action  or  lack 
of  action  and  attitude  of  his  medical  brethren  and  medical 
A-  organizations  towards  him  —  the  best  available,  honest, 
humane  and  intelligent  machinery  would  be  set  in  motion 
for  the  immediate  care  of  the  average  honest  sufferer  from 
addiction-disease,  and  for  the  discouragement  of  under- 
world or  underground  exploitation.  This  has  been  demon- 
strated. It  would  react  furthermore  as  a  stimulus  to  the 
education  of  the  physician,  to  familiarize  himself  with 
the  scientific  and  medical  facts  of  this  disease. 

Another  immediate  provision  is  the  establishing  under 
proper  supei'vision  and  management,  especially  as  to  com- 
petent medical  management,  and  without  possibilities  of 
humiliation  and  interference  with  self-support,  of  stations 
or  clinics  at  which  those  who  for  financial  or  other  reasons 
are  unable  to  secure  reputable  and  honest  medical  help, 
may  obtain  their  necessary  opiate  at  minimum  expense  and 
in  physically  necessary  amounts  to  enable  them  to  work 
and  support  themselves  and  families,  without  resorting 
to  underworld  associations  and  illicit  commerce.  Such 
clinics  might  be  established  in  connection  with  the  various 
hospitals  on  the  same  basis  as  their  other  medical  and 
surgical  clinics  or  dispensaries,  and  in  connection  with 
various  health  departments.  In  them  the  narcotic  addict 
could  not  only  be  supplied  with  opiate  medication,  but 
taught  the  nature  of  his  disease  and  the  elements  and 
principles  of  its  control  and  be  given  such  medication 
other  than  opiate  for  the  relief  of  such  associated  or  inter- 
current conditions  as  might  exist.  Such  clinics  would 
have  great  educational  value,  as  well  as  fulfilling  a 
therapeutic  need. 

Pending  further  study  and  investigation  and  education 
into  narcotic  drug  addiction-disease  and  the  conditions 
surrounding  it,  and  pending  the  widespread  acceptance 
and  recognition  of  practical  and  desirable  procedures  in 
the  handling  of  the  disease,  and  pending  the  provision  of 


GENERAL  SURVEY  1^5 

sufficient  and  scientifically  adequate  accommodations  for 
the  army  of  those  who  seek  relief  —  legitimate  supply  of 
the  drug  of  addiction  under  medically  competent  and 
intelligent  direction  fulfills  a  great  economic  and  sociologic 
and  medical  need. 

The  financial  possibilities  of  commercial  exploitation 
of  the  sufferings  of  addiction-disease,  combined  with  gen- 
eral ignorance  of  the  true  nature  of  the  addiction  condi- 
tion, are  responsible  for  the  tremendous  increase  of  late 
of  narcotic  addiction,  of  non-medical  or  non-therapeutic 
origin,  among  the  youth.  In  ignorance  of  actual  physical 
results,  not  knowing  nor  ever  having  been  told  that  they 
are  contracting  a  disease  of  torturing  manifestations,  act- 
uated by  curiosity  and  search  for  adventure,  in  some 
cases  stimulated  by  unfortunate  spectacular  publicity,  the 
youths  fell  easy  prey  to  the  agents,  male  and  female,  of 
the  drug  trafiicker.  The  trafficker's  intended  consumma- 
tion is  reached  when  these  youths  finally  become,  to  their 
surprise  and  consternation,  through  the  development  of 
addiction-disease  and  physical  dependence  upon  narcotic 
drug,  enforced  and  continued  customers  and  in  some 
cases,  virtual  slaves. 

Those  who  are  interested  in  prostitution  and  in  so- 
called  "  white-slavery ''  would  do  well  to  turn  their  at- 
tention to  the  chains  forged  by  the  suffering,  and  the  fear 
of  suffering,  experienced  by  those  who  have  developed  nar- 
cotic drug  addiction-disease. 

It  is  this  class  of  youthful  addicts  that  has  so  alarm- 
ingly increased  since  the  enforcement  of  the  various  nar- 
cotic laws.  I  have  previously  called  attention  to  this 
situation,  and  also  to  the  fact  that  for  this  increase  the 
laws  themselves  are  not  so  much  to  be  blamed  as  is  the 
totally  inadequate  meeting  of  the  clinical  and  therapeutic 
and  educational  needs  of  the  narcotic  drug  situation. 
There  has  been  practically  no  organized  scientific,  medical 
or  public  health  activity,  so  far  as  I  know,  directed  to- 


1^6         THE  NARCOTIC  DRUG  PROBLEM 

wards  tlie  clinical  and  laboratory  investigation  of  this 
disease  —  towards  a  dispassionate  review,  analysis  and 
testing  out  of  tlie  truths  and  errors  of  its  literature  —  to- 
wards an  investigation  of  the  scientific  and  other  qualifica- 
tions and  experience  of  those  whose  utterances  or  writings 
influence  medical  and  lay  opinion  and  action,  towards  the 
establishing  of  pathological  and  physical  facts  and  reac- 
tions and  of  clinical  symptomatology  and  phenomena  as 
fundamental  bases  for  its  rational  handling  and  therapeu- 
tics, and  for  practical  education  of  the  public  as  to  its 
sufferings  and  dangers. 

The  neglect  of  this  education  is  largely  indirectly  re- 
sponsible for  illicit  traffic  in  narcotic  drugs.  Illicit  and 
underground  traffic  exists  because  it  is  profitable.  This 
is  the  direct  and  immediate  reason  for  its  existence. 
Every  new  addict  made  of  an  adventurous  youth  means 
a  new  customer  for  the  smugglers  and  vendors.  If  that 
adventurous  youth  had  been  taught  the  facts  of  the  physi- 
cal hell  of  the  "  withdrawal  signs  "  of  opiate  addiction- 
disease  —  if  he  knew  the  sufferings  attendant  upon  body- 
need  for  opiate  drug  —  if  he  knew  that  any  red-blooded 
animal  will  develop  this  physical  body  need  if  opiate  drug 
is  administered  for  a  sufficiently  prolonged  period  —  that 
no  living  being  is  immune  to  the  development  of  this 
disease  —  if  he  thought  of  addiction  as  he  thinks  of  tuber- 
culosis, and  as  he  is  now  being  taught  to  regard  venereal- 
disease,  instead  of  it  as  being  something  vague  and  sur- 
rounded by  a  halo  of  adventure  and  experience,  he  would 
not  fall  an  easy  victim  to  the  agents  of  the  trafficker.  In 
other  words,  the  most  potent  activity  in  the  arrest  of  de- 
velopment of  even  the  vicious  and  criminal  aspects  of 
the  narcotic  addiction  situation  lies  in  education.  Laws 
and  their  enforcement  in  the  control  of  the  incorrigible 
and  vicious  will  always  be  a  necessity,  but  laws  and  their 
administration  alone  are  not  sufficient  for  the  control  of 
the  many-sided  addiction  situation.     Even  in  the  control 


GENERAL  SURVEY  127 

of  smuggling  and  illicit  traffic  we  need  the  application 
of  every  available  influence  capable  of  exertion,  not  only 
upon  its  end  results  but  upon  the  machinery  of  its  origin 
and  development.  As  so  much  of  it  originates  and  de- 
velops through  ignorance,  the  method  of  its  remedy  lies 
in  education,  education  as  to  the  facts  of  narcotic  drug 
addiction-disease. 

It  is  ignorance  also  that  has  stamped  the  honest  and 
innocent,  v^orthy  and  intelligent,  and  often  illustrious 
suiferer  from  narcotic  addiction-disease  with  the  attributes 
and  characteristics  of  the  inherently  irresponsible  or  other- 
wise incapable  of  self-guidance  and  self-restraint.  The 
ignorance  of  the  facts  of  addiction-disease  has  taken  from 
these  people  even  their  ordinary  legal  and  public  rights 
in  any  issue  which  involved  the  possible  revelation  of 
their  addiction.  It  has  placed  them  in  a  position  where 
any  procedure  which  might  reveal  their  narcotic  medica- 
tion would  expose  them  to  public  gaze  as  members  of  a 
popularly  despised  and  unworthy  class  of  individuals. 
Until  very  recently  the  testimony  of  a  known  narcotic 
addict  has  been  almost  as  a  rule  of  no  value  in  a  court 
of  law.  Irrespective  of  a  life-time  of  honesty  and  accom- 
plishment, the  revelation  of  a  minute  might  destroy  the 
reputation  and  standing  of  many  years.  Whatever  the 
injustices  or  grievances  suffered  by  an  addict,  he  could 
not  hope  to  evoke  the  protection  or  rights  accorded  an 
ordinary  individual  under  statute  law  without  the  prac- 
tical certainty,  if  his  addiction  became  revealed,  of  per- 
sonal, social  and  economic  detriment  far  in  excess  of  the 
legal  rights  to  which  he  was  entitled.  The  continuation 
of  whatever  is  spurious  or  unworthy  in  methods  of  hand- 
ling, advertised  or  otherwise,  lies  partly  in  the  fact  that 
the  former  patient  cannot  afford,  however  great  his  physi- 
cal or  other  damage,  to  make  public  the  existence  of 
addiction-disease  by  the  instituting  of  a  suit  for  malprac- 
tice or  other  civil  or  criminal  procedure.     This  alone  has 


128         THE  NARCOTIC  DRUG  PROBLEM 

been  one  of  the  factors  in  lack  of  progress  and  in  the 
persistence  of  narrow  vision  or  false  conception.  He  is 
in  effect,  however  high  his  personal,  moral  and  other 
status,  deprived  of  some  of  his  constitutional  rights,  simply 
because  he  has  developed  addiction-disease. 

The  great  numbers  of  innocent  and  worthy  unsuspected 
sufferers  from  this  disease,  who  could  not  by  any  stretch 
of  wildest  imagination,  be  regarded  as  mentally  or  mor- 
ally abnormal  or  subnormal  have  therefore  been  placed 
in  a  position  where  they  could  not  afford  to  demand 
their  rights  or  state  their  case.  Their  problems  are  only 
recently  beginning  to  receive  general  consideration.  Their 
cases  have  compelled  us  to  revise  our  conception  of  the 
narcotic  addict,  and  to  question  ourselves  as  to  the  neces- 
sity for  their  continued  addiction  over  the  years  of  their 
addiction.  Tor  their  own  good  and  that  of  society,  what 
shall  we  do  with  them,  and  what  can  we  do  for  them? 
In  the  present  state  of  public  opinion  and  public  attitude 
towards  narcotic  addicts  in  general  would  it  benefit  either 
them  or  society  to  class  them  merely  as  "  drug  addicts  " 
along  with  the  drug-users  of  other  types  of  individuals 
and  other  personal  characteristics  for  administrative 
handling  by  detailed  administrative  supervision  and  con- 
trol ?  Can  the  same  administrative  and  other  methods 
which  admittedly  must  be  employed  to  protect  society 
from  the  manifestly  unfit  accomplish  anything  of  good 
in  the  cases  of  these  responsible  and  valuable  citizens? 

Until  there  is  a  truer  understanding  of  addiction-disease, 
and  a  wider  appreciation  of  the  facts  that  the  personal 
attributes  of  its  victims  differ  as  widely  as  those  of  cardiac 
or  any  other  disease  condition,  and  that  merely  because 
a  man  has  contracted  this  disease  is  no  reason  for  regarding 
him  as  in  any  way  unworthy  or  unfit  —  will  stringent 
and  drastic  forcible  regulative  measures  directed  against 
mere  use  of  narcotics  work  out  to  the  advancement  or 
hindrance  of  ultimate  solution  and  to  the  ultimate  benefit 


GENERAL  SURVEY  129 

or  liann  of  society?  These  are  the  questions  to  be  ap- 
plied to  all  restrictive  administrative  activities.  The 
problem  of  the  care  of  the  worthy  and  innocent  addict 
in  such  a  way  as  not  to  unnecessarily  harm  him  nor  deprive 
his  family  and  society  of  his  competent  activity  is  just 
as  important  as  the  handling  of  the  addict  of  the  type  of 
individual  from  whom  society  must  be  protected.  The 
large  numbers  of  worthy  and  valued  citizens  who  are  in- 
dividually and  personally  social  and  economic  assets  and  , 
who  are  sufferers  from  addiction-disease  constitute  a  very<^ 
important  consideration  in  the  narcotic  problem.  n 

They  certainly  are  not  fit  subjects  for  enforced  custodial 
and  correctional  handling,  and  if  such  were  forced  upon 
them  they  would  be  seriously  harmed,  personally,  socially,  . 
economically  and  physically.  Very  many  of  them  our 
equals  or  betters,  we  have  no  right  to  subject  them  to 
associations  and  experiences  which  we  ourselves  would 
rebel  against  and  be  humiliated  by  simply  because  they 
have  developed  a  disease  condition  from  which  no  one  of 
us  is  immune. 

Where  is  the  blame  for  their  continued  addiction  ?  Cer- 
tainly not  because  of  lack  of  effort  on  their  part.  Ad- 
dicted for  years,  they  have  tried  one  after  another  of 
the  various  and  diverse  treatments  and  so-called  cures  with- 
out success  or  benefit.  Is  the  blame  theirs  for  lack  of 
success  and  cure,  or  has  there  been  something  wrong  in 
our  treatment  and  handling  of  them?  Did  we  know 
enough  about .  addiction-disease  to  treat  them  intelligently 
and  to  exercise  upon  their  cases  the  same  professional 
skill  and  technical  ability  that  we  have  been  educated 
and  trained  to  apply  to  other  diseases  ?  In  the  light  of 
present  available  clinical  information  and  study,  and  in 
the  light  of  recent  and  competent  laboratory  research,  we 
are  forced  to  admit  that  we  have  not  treated  our  addiction 
sufferers  with  sympathetic  understanding  and  clinical  com- 
petency, and  that  the  blame  for  past  failure  to  control  the 


130         THE  NARCOTIC  DRUG  PROBLEM 

narcotic  drug  problem  rests  largely  upoii  the  educational 
inadequacy  of  the  past. 

We  are  in  a  stage  of  transition  in  our  concepts  of,  atti- 
tude towards,  and  handling  of  the  narcotic  addict.  Serious 
consideration  of  drug  addiction  as  a  problem  of  clinical 
and  internal  medicine,  and  of  experimental  laboratory  re- 
search is  a  comparatively  new  thing  to  a  majority  of  the 
medical  profession,  and  of  course  also  to  legislators  and 
administrators.  We  should  all  remember  that  no  matter 
how  strong  we  are  in  our  beliefs  and  theories,  there  are 
many  others  whose  experiences  and  results  have  caused 
them  to  hold  just  as  strongly  to  opposite  theories  and  be- 
liefs, and  that  we  are  all  on  trial  for  the  validity  and  extent 
of  practical  application  of  our  beliefs  and  theories. 

Each  new  theory  or  belief  that  is  brought  forward  should 
be  taken  simply  for  record  and  investigation.  Much  that 
we  believe  to-day  we  know  to-morrow  to  be  based  upon 
misinterpretation  and  lack  of  complete  information. 
Much  that  we  believed  in  the  past  to  apply  to  and  solve 
conditions,  we  found  later  to  have  been  merely  based 
upon  observations  of  distracting  incidentals  or  non-basic 
aspects  and  phases.  What  we  need  is  competent,  disin- 
terested, and  honest  effort  to  get  together  and  evaluate  all 
available  material  of  whatever  sort  and  from  whatever 
source.  If  it  were  possible  of  accomplishment,  it  would 
be  of  advantage  to  get  together  in  open  and  frequent 
discussion  the  various  workers  in  the  field.  We  are  all 
partly  wrong  and  partly  right.  There  is  no  one  of  us 
who  cannot  learn  from  any  one  of  the  others.  The  real 
end  of  effort  should  be^  not  to  prove  one  or  another  of  us 
right,  but  to  take  each  from  the  other  whatever  is  of  value 
and  all  to  contribute  in  true  scientific  spirit  of  broad 
tolerance  towards  the  ideas  of  others  and  of  willingness 
to  correct  or  modify  ideas  and  theories  of  our  own,  search- 
ing for  no  panaceas  or  specifics,  medical,  legislative  or 
administrative,  simply  hunting  for  truth  wherever  we  may 


GENERAL  SURVEY  131 

find  it  and  applying  it  intelligently  to  meet  the  needs  of 
the  individual. 

There  is  too  mnch  work  to  be  done^  and  the  situation 
is  too  urgent  for  remedy,  to  permit  of  longer  delay  in 
scientific  approach.  Under  present  conditions,  no  man's 
announcement  of  theory  or  of  remedy  is  to  be  taken  as 
ultimate  authority,  but  simply  as  his  opinion  based  on  his 
personal  deductions,  and  his  personal  experience,  to  be 
evaluated  in  accordance  with  the  extent  and  variety  of 
his  personal  experience  in  the  light  of  his  individual  ability 
and  training. 

Education  and  training  are  the  best  hopes  we  have  as  a 
foundation  for  the  alleviation  of  present  conditions  and 
the  prevention  of  their  further  spread.  Lack  of  appre- 
ciation of  and  of  ability  to  recognize  and  meet  varied  and 
various  clinical  and  other  indications  for  treatment  and 
handling  under  widely  different  circumstances  and  in 
widely  differing  individuals  means  failure  in  a  majority 
of  cases,  and  throws  a  burden  upon  society  and  a  com- 
plexity of  problems  upon  municipal,  state  and  federal  au- 
thorities which  they  are  unable  to  meet.  Each  class  of 
workers  should  be  working  in  its  own  field  in  co-operation 
with  those  working  in  other  fields,  none  trying  to  dominate 
the  rest,  but  each  giving  to  the  others  credit  for  honest 
effort  and  appreciation  of  difficulties  to  be  made  easier  if 
possible. 

All  possible  forces  should  be  encouraged  to  the  work 
of  study  and  investigation  and  education.  A  campaign  of 
medical  and  lay  investigation  and  education  will  require 
a  much  shorter  time  than  a  continuous  trying  out  of  various 
panaceas,  medical,  legislative  or  administrative.  Also,  it 
will  bring  far  more  satisfactory  and  earlier  results.  The 
narcotic  wards  of  our  great  charity  hospitals  should  be 
made  use  of  for  honest  unbiased  and  trained  clinical  and 
laboratory  study.  The  narcotic  addict  himself  should  be 
given  a  much  wider  hearing  than  he  has  in  the  past  re- 


132         THE  NARCOTIC  DRUG  PROBLEM 

ceived.  The  mass  of  honest  and  intelligent  narcotic  ad- 
dicts should  be  encouraged  to  tell  their  stories  and  their 
experiences,  and  should  receive  a  fair  and  unbiased  hear- 
ing as  to  the  reactions  upon  them  of  various  measures 
proposed.  We,  doctors,  legislators,  administrators  are  in 
truth  as  much  on  trial  with  the  narcotic  addict  and  with 
society  for  our  understanding  and  handling  of  the  narcotic 
addict  and  his  problems  as  the  addict  is  for  his  condition. 
The  remedy  is  plain,  and  the  necessity  for  immediate 
activity  is  obvious.  Education  —  scientific  medical  and 
lay,  administrative  and  public  health  education  is  the  lack- 
ing element  or  factor  in  the  solution  of  the  many  sided 
narcotic  drug  problem.  Appreciation  of  addiction-disease 
and  what  it  may  mean  in  the  individual  should  be  as 
widespread  and  as  comprehensive  as  possible  and  at  the 
earliest  possible  moment. 

Without  a  basis  of  generally  recognized  and  widely  ap- 
preciated fundamental  facts,  there  can  be  no  competent 
treatment,  legislation,  administration  or  judicial  decision. 
There  can  be  no  competent  evaluation  of  the  merits  and 
defects  of  various  measures  promulgated,  medical,  legis- 
lative or  administrative.  There  can  be  no  competent  selec- 
tion of  those  in  whose  hands  shall  lie  the  handling  of  a 
tremendous  problem,  a  problem  of  disease,  of  sociology, 
of  economics,  of  public  health  and  welfare.  There  can 
be  no  competent  evaluation  of  the  remedies  advanced, 
nor  of  the  qualifications  and  true  authority  of  those  who 
recommend  them.  Under  such  conditions  various  meas- 
ures or  procedures  in  their  adoption  or  discarding  or 
application  must  depend  more  upon  the  publicity  and  other 
influence  of  their  proponents  than  upon  their  intrinsic 
values. 

There  are  always  some  things  about  any  condition  which 
either  are  or  are  not,  some  things  which  are  physically 
determinable.     The  basic   facts   of  addiction-disease   are 


GENERAL  SURVEY  133 

now  physically  determinable.  There  are  many  material 
and  obvious  and  easily  demonstrable  physical  facts  of 
greatest  value  to  the  medical  profession  and  to  the  laity, 
facts  which  are  still  but  little  appreciated,  and  not  widely 
known. 

These  facts  in  addiction-disease  could  be  easily  investi- 
gated. The  various  conflicting  statements  of  different 
schools  of  thought  or  of  observers  working  from  different 
angles  should  be  investigated,  evaluated  and  correlated  — 
taking  from  each  whatever  is  useful,  determining  its  true 
sphere  of  application  and  making  it  available  to  all. 
Every  possible  interest  or  worker  should  be  encouraged, 
and  every  source  of  information  sought  out,  not  least  among 
them  the  honest  and  intelligent  sufferer  from  addiction- 
disease  of  many  years  duration  whose  knowledge  of  the 
facts  of  his  condition,  and  efforts  to  control  it,  and  search 
for  and  trial  of  remedy  and  remedies  for  it,  and  the  ex- 
periences and  problems,  social,  economic  and  personal, 
which  its  possession  has  forced  upon  him  would  constitute 
a  touchstone  of  greatest  value  for  the  determination  of 
validity  of  promulgated  measures  and  procedures. 

The  wards  of  the  great  charity  hospitals,  the  institu- 
tions of  science  and  medical  experiment  and  research, 
the  Departments  of  Health,  and  the  Public  Health  Serv- 
ices are  in  existence  and  are  equipped  for  the  early  deter- 
mination of  clinical,  and  laboratory  facts,  and  for  their 
dissemination.  These  are  the  things  towards  which  their 
activities  are  directed  in  other  diseases  and  conditions 
affecting  public  welfare  and  public  health.  It  would  take 
a  very  short  time  to  determine  the  physical  facts  of  ad- 
diction-disease —  to  establish  finally  and  conclusively  its 
clinical  symptomatology  and  constant  reactions  and  phe- 
nomena for  authoritative  and  educational  dissemination. 
Every  one  of  us  who  has  written  in  description  or  ex- 
position of  his  study  and  observations,  together  with  what 
we  have  written  and  taught,  should  be  made  the  subject 


134<         THE  NARCOTIC  DRUG  PROBLEM 

of  critical  and  unbiased  investigation,  and  whatever  of 
truth,  we  have  stated  should  be  made  the  possession  of 
all.  The  experimental  development  of  addiction-disease 
in  dogs  and  other  experimental  laboratory  animals^  the 
symptoms  and  phenomena  observed  in  them  recorded  by 
instruments  such  as  the  sphygmomanometer  and  the 
sphygmogTaph  and  paralleling  similar  records  and  obser- 
vations upon  the  addicted  human,  the  reactions  of  the 
serum  of  these  animals  injected  into  the  non-addicted  of 
their  species  are  not  to  be  lightly  ignored,  and  should  be 
matters  of  common  scientific  knowledge.  The  manifesta- 
tions of  addiction-disease  in  the  new-born  developed  in 
the  infant's  body  prenatally  long  before  vice  or  habit  or 
appetite  can  be  possibly  considered  as  causative  factors, 
demand  more  than  casual  consideration  and  have  a  signi- 
ficance much  deeper  than  as  occasional  curiosities. 

An  educational  campaign  as  to  the  facts  of  addiction 
would  save  many  an  innocent  person  from  the  contraction 
of  the  disease,  and  many  a  present  sufferer  from  unin- 
telligent handling.  Authoritative  bodies  with  sufficient 
power  and  independence  might  easily  institute  unbiased 
review  of  what  is  written,  and  trial  and  proving  out  of 
what  is  stated  by  various  writers,  and  give  out  their  find- 
ings for  the  guidance  of  future  work  and  action.  Hospi- 
tals and  public  institutions  for  the  handling  of  narcotic 
addicts  may  be  erected  Without  comprehension  of  addic- 
tion-disease and  full  and  complete  familiarity  with  its 
manifestations,  the  possession  of  those  who  work  in  them, 
will  they  accomplish  anything  of  good  ? 

The  deduction  from  the  testimony  of  the  Whitney  In- 
vestigation and  from  other  sources  leads  to  the  conclusion 
that  one  of  the  reasons  why  the  narcotic  addict  does  not 
go  to  many  of  our  present  institutions  is  that  he  is  more 
afraid  of  them,  and  anticipates  more  suffering  in  them 
than  he  cares  to  face  in  view  of  the  fact  that  neither  from 
previous  personal  experience  or  from  repute  he  has  little 


GENERAL  SURVEY  135 

hope  of  being  discharged  from  them  in  a  condition  of 
physical  competency  with  his  addiction  mechanism  ar- 
rested. He  sees  no  use  in  going  through  them  only  to 
come  out  in  a  condition  where  he  will  have  to  revert  to 
his  opiate  to  enable  him  to  endure  and  work.  This  is 
not  an  all-inclusive  statement.  It  expresses,  however,  the 
frequent  response  of  the  addict  seeking  advice  when  asked 
why  he  does  not  go  to  the  municipal  institutions  for  treat- 
ment. Again  then  the  work  of  those  in  the  institutions 
will  be  the  determinating  factor  in  their  success  or  failure, 
and  their  education  is  the  dominant  element  required  for 
success.  Some  interesting  observations  upon  this  point 
will  be  found  in  the  Yearly  Report  for  the  Department  of 
Correction  of  N'ew  York  City,  1915. 

Of  public  clinics  the  same  thing  may  be  said.  Whether 
they  react  to  the  benefit  of  the  addict  and  of  the  com- 
munity, or  to  the  harm  of  the  addict  and  community  will 
depend  upon  their  intelligent  understanding  and  competent 
management. 

Hospitals  and  clinics  might  be  made  into  sorely  needed 
educational  centers  for  the  training  of  doctors  and  nurses 
to  go  out  and  take  up  the  work  of  the  care  of  the  addict 
—  either  private  or  institutional. 

Education  is  the  great  need  of  the  hour.  Until  it  is 
accomplished  all  else  will  fail.  Until  we  all  know  what 
we  are  dealing  with,  how  can  we  hope  to  successfully 
handle  it  ?  It  is  to  be  hoped  that  the  time  is  not  far  dis- 
tant when  in  every  medical  school  and  hospital  will  be 
taught  in  principle  and  practice,  in  class-room  and  clinic 
all  that  is  known  or  will  be  known  of  the  pathology, 
symptomatology,  physical  phenomena  and  rational  thera- 
peutics of  narcotic  addiction-disease.  It  is  to  be  hoped 
that  in  school  and  college,  in  pulpit  and  press,  the  facts  of 
addiction  will  be  presented  in  their  practical  existence, 
stripped  of  spectacularity ;  a  calm,  cold  presentation  of 
basic  facts.     There  is  no  subject  upon  which  philanthropy 


136         THE  NARCOTIC  DRUG  PROBLEM 

can  better  expend  its  forces  than  to  this  end  of  education 
as  to  addiction-disease  and  humane  help  to  its  sufferer. 

In  the  past  the  problem  of  control  of  addiction  has 
been  "  What  shall  be  done  with  or  what  shall  be  done  to 
the  narcotic  addict  to  make  him  stop  using  drugs  ?  "  It 
is  now  gradually  coming  to  be  realized  that  the  true  prob- 
lem is  "  What  can  be  done  for  the  narcotic  addict  to 
relieve  him  of  the  physical  necessity  of  using  drugs  ?  "  and 
^'  What  can  be  done  to  so  educate  the  public  as  to  the  facts 
of  addiction,  so  that  this  disease  will  claim  as  few  victims 
as  possible  ? " 

In  this  change  of  attitude  lies  the  hope  for  the  future. 
Some  of  the  narcotic  addicts  will  have  to  be  done  with 
or  done  to.  They  are  the  inherently  irresponsible,  vicious 
or  defective.  They  demand  care  and  restraint  irrespec- 
tive of  their  addiction.  The  mass  of  addicts,  however, 
need  something  done  for  them.  They  are  clinical  prob- 
lems of  internal  medicine,  victims  of  a  definite  disease, 
characteristic  in  its  symptomatology,  reactions  and  phe- 
nomena, a  disease  which  will  before  long  come  to  be  known 
as  clinically  and  therapeutically  controllable  and  arrest- 
able. 


APPE]^DIX 
HUMAN"  DOCUMENTS  — PEESONAL  STATEMENTTS 

The  great  importance  of  the  real  story  of  the  sufferer  from 
narcotic  drug  addiction-disease  has  been  referred  to  several 
times  in  this  book.  It  had  been  my  first  intention  to  include 
in  the  course  of  the  various  discussions,  stories  and  state- 
ments of  narcotic  drug  addicts  illustrative  of  the  various 
matters  discussed,  and  to  take  them  from  my  own  collection 
of  addiction  histories. 

That  I  might  avoid  any  personal  controversy,  however,  as 
to  their  personality  or  reliability,  and  also  to  make  such  state- 
ments free  from  any  possible  hint  of  influence  or  bias,  I  have 
taken  them  from  medical  literature  and  am  using  them  as  an 
appendix. 

In  December,  1917,  American  Medicine  published  a  spe- 
cial addiction  number,  containing  statements  written  for  it 
by  addicts  of  evident  and  vouched  for  intelligence  and  stand- 
ing, stating  their  personal  experiences  and  personal  views. 

Through  the  courtesy  of  American  Medicine  and  its  editors, 
I  am  reproducing  these,  believing  that  they  are  of  great 
value  and  that  they  illustrate  many  of  the  discussions  which 
appear  in  this  book. 

HUMAISr  DOCUMENTS  ^ 
THE  PEESONAL  SIDE  OF  DRUG  ADDICTION 

Some  Views  ok  Drug  Addiction  —  Personal  and  Legal 
By  a  Pbominent  Member  of  the  New  Yoek  Bab 
A  half  dozen  years  ago  I  had  a  long,  severe  attack  of  gall- 

1  For  obvious  reasons  the  names  of  the  authors  of  these  con- 
tributions are  not  given.  The  editor,  however,  has  every  one  of 
them,  and  has  taken  especial  care  to  establish  the  authenticity  and 
good  faith  of  each  article.     Each  contribution  appears  as  received. 

137 


138         THE  NARCOTIC  DRUG  PROBLEM 

stones  and  inflammation  of  the  gall-bladder.  I  suffered  so 
much  pain  that  the  physicians  gave  me  morphine  for  nearly 
a  year.  When  I  got  better  I  tried  my  very  best  to  get  along 
without  the  drug,  but  could  not.  I  came  to  a  physician  in 
N'ew  York  for  treatment  who  had  made  a  special  study  of 
drug  addiction  and  is  a  recognized  authority  on  that  subject. 
However,  he  could  not  help  me  at  that  time  on  account  of  a 
recurrence  of  my  gall-bladder  inflammation  with  severe  jaun- 
dice and  fever. 

Since  that  time  I  have  tried  repeatedly  to  stop  and  reduce 
the  quantity  of  the  drug,  but  have  found  it  impossible  because 
of  the  physical  pain  and  exhaustion  due  to  the  lack  of  the 
drug.  This  is  unbearable.  I  have  since  then  kept  my  daily 
amount  of  morphine  medication  at  a  minimum  which  permit- 
ted me  to  work  and  to  maintain  good  health  and  bodily  func- 
tion. The  idea  which  I  have  heard  so  often  expressed,  that 
addicts  tend  to  increase  their  daily  intake  of  narcotic,  is 
certainly  untrue  in  my  case,  and  there  seems  to  me  no  reason 
nor  temptation  to  do  so.  I  have  simply  found  the  smallest 
amount  which  would  keep  me  from  physical  suffering,  and 
have  experienced  no  difficulty  in  maintaining  that  dosage, 
except  in  occasional  emergencies  of  gall-bladder  attacks  or 
other  crises,  after  which  I  found  it  a  simple  matter  to  dis- 
continue the  excess  dosage.  As  I  have  never  experienced  the 
slightest  pleasurable  or  sensually  enjoyable  sensations  from 
the  administration  of  morphine,  there  seems  to  me  no  founda- 
tion for  this  prevalent  idea  of  tendency  to  increase.  It  may  be 
true  of  the  degenerate  who  has  become  addicted,  but  it  cer- 
tainly is  untrue  in  my  case,  and  must  be  untrue  of  the  thou- 
sands like  me  whose  misfortune  it  has  been  to  become  afflicted 
with  this  condition. 

Recently  I  have  again  consulted  specialists,  and  it  seems 
that  with  my  condition  I  must  continue  the  administration  of 
morphine  for  the  present,  and  perhaps  for  the  rest  of  my  life. 
Physical  conditions  render  present  attempts  to  discontinue  its 
use  impractical,  undesirable  and  dangerous. 

Now  what  am  I  to  do  under  the  present  "  Drug  Habit " 
laws  of  this  State?  I  am  a  lawyer  long  past  middle  age  — 
have  held  important  state  and  judicial  positions,  and  many 


APPENDIX  139 

positions  of  responsibility  and  trust.  It  would  be  ruinous 
to  me  if  my  addiction  condition  became  public. 

This  law  was  enacted  to  control  the  drug  traffic  and  to  stop 
the  evils  which  are  connected  with  it.  In  many  respects  it  is 
an  excellent  law,  but  the  provisions  which  require  the  record 
of  the  name,  age  and  residence  of  the  addict  to  be  filed  in  the 
Board  of  Health  Office  is  outrageous.  It  does  not  affect  the 
underworld,  for  they  don't  care  and  avoid  registration  by  not 
going  to  those  who  have  to  register  them.  But  see  the  posi- 
tion of  a  man  who  has  a  good  reputation  and  standing  in  the 
community  —  forever  recorded  in  the  records  of  the  State 
Board  of  Health  as  a  "  dope  fiend/'  even  though  his  condition 
is  not  the  result  of  his  own  acts  or  desires  and  absolutely 
beyond  his  control. 

This  part  of  the  law  which  requires  the  recording  of  the 
name,  age  and  residence  of  the  addict  should  be  repealed. 
The  only  effect  of  these  provisions  is  to  record  the  addict  as 
what  everybody  considers  a  "  dope  fiend  "  or  force  him  to  go 
to  the  smugglers  for  his  drug.  He  must  either  place  his 
good  name  and  social  and  economic  position  in  constant 
jeopardy  or  in  some  way  or  other  evade  the  law  with  its  at- 
tendant penalty,  and  constant  fear  of  detection.  I  should  not 
be  surprised  if  it  finally  develops  to  be  the  fact  that  a  major- 
ity of  decent  sufferers  from  this  condition  have  chosen  the 
latter  course  as  the  lesser  of  evils. 

I  am  informed  that  the  Health  Department  has  recently 
issued  monthly  registration  blanks  to  physicians,  demanding, 
in  addition  to  the  name,  age  and  residence  of  the  addict,  the 
date  and  amounts  of  each  prescription  together  with  other  in- 
formation as  to  the  individual  cases  treated.  This  makes 
conditions  still  more  obnoxious  and  unbearable.  Further- 
more, this  action  of  the  authorities  of  the  Board  of  Health  is 
imwarranted  and  illegal.  There  is  nothing  in  the  powers  of 
the  Board  of  Health  which  permits  them  such  action,  and  such 
action  is  without  any  justification  in  the  letter  of  the  law  or 
in  any  possible  interpretation  of  the  spirit  and  intent  of  the 
law. 

The  data  demanded  were  submitted  to  the  Legislature  as 
provisions  in  the  law  when  the  bill  was  being  considered,  and 


140         THE  NARCOTIC  DRUG  PROBLEM 

were  rejected.  The  Health  Department  is  usurping  the  pow- 
ers of  the  Legislature,  which  it  has  no  authority  to  do.  The 
law  plainly  states  what  the  physician  shall  report  and  the 
Board  of  Health  has  no  power  to  require  additional  matters. 
Such  action  constitutes  illegal  interference  with  the  rights  of 
physician  and  patient  as  to  matters  of  treatment  and  as  to 
violation  of  professional  confidence.  It  is  my  opinion  that  a 
narcotic  addict  might  have  grounds  for  legal  procedure  against 
a  physician  who  furnished  such  information  as  the  Health  De- 
partment demands. 

Conditions  in  New  York  today,  affecting  the  honest  addict, 
constitute  in  effect  persecution  of  the  sick.  It  is  bad  enough 
to  be  afflicted  with  this  disease.  Agonizing  as  gall-stone  at- 
tacks have  been,  the  physical  suffering  from  lack  of  morphine 
in  an  addict  is  worse.  Added  to  this  is  the  knowledge  that 
your  name  is  on  file  at  Albany,  and  perhaps  elsewhere,  as  an 
addict.  You  know  that  disclosure  of  your  condition  will  ruin 
you  and  disgrace  your  family.  You  are  potentially  subject 
to  leakage  from  those  records  and  the  attendant  possibilities 
of  blackmail  and  other  persecution.  Such  conditions  tend  to 
force  and  undoubtedly  have  forced  many  innocent  and  honest 
addicts  of  good  social  and  economic  standing  to  become  crimi- 
nals by  obtaining  their  necessary  opiate  medicine  through 
illegal  channels. 

Something  certainly  should  be  done  to  remedy  existing  con- 
ditions and  existing  laws.  The  great  State  of  New  York 
should  not  place  its  unfortunate  sick  in  their  present  position. 

The  Personal  History  of  a  Medical  Addict 
By  a  Well-known  American  Physicl&.n 

When  the  suggestion  was  first  made  by  a  medical  friend  that 
I  should  write  a  short  account  of  my  personal  experience 
as  a  drug  addict,  particularly  in  reference  to  my  status  as 
a  practitioner  of  medicine,  the  idea,  for  obvious  reasons,  was 
repellent,  notwithstanding  the  fact  that  my  identity  should 
not  be  disclosed.  But  after  mature  deliberation,  I  realized 
that  it  is  largely  due  to  this  natural  reticence  on  the  part  of 
those  in  position  to  speak,  that  the  unfortunate  addict  is  re- 


APPENDIX  il41 

garded  as  a  social  pariah  by  the  general  public,  and  that 
tmtil  the  medical  profession  shall  acquire  more  accurate  and 
less  distorted  knowledge  of  this  serious  question,  we  cannot 
hope  for  any  improvement  along  these  lines.  IJntil  this  is 
done,  cruel  and  unjust  laws  will  be  enforced,  wretched  victims 
will  be  imprisoned  as  felons,  and  what  is  more  distressing, 
these  unfortunates  will,  in  many  instances,  be  subjected  to 
torture  to  which  death  is  preferable  —  and  not  infrequently 
results.  All  this  is  based  upon  the  accepted  theory  that  drug 
addiction  is  a  vicious  habit  requiring  only  a  little  fortitude  and 
strength  of  will  on  the  part  of  the  wretched  victim  to  rid 
himself  of  it,  while  the  saddest  feature  of  it  all  is  that  this 
canker,  eating  at  the  very  heart  of  the  nation  itself,  blighting 
and  destroying  the  lives  of  many  useful  men  and  women,  is 
not  being  reached. 

That  the  average  medical  men  can  remain  so  hopelessly,  I 
might  say  criminally,  negligent  of  the  true  conditions  of  drug 
addiction  is  a  cause  for  wonder  as  well  as  condemnation.  If 
the  perusal  of  my  paper  induces  even  one  conscientious 
physician  to  seek  more  definite  information  upon  this  tre- 
mendously vital  subject,  my  efforts  shall  not  have  been  in  vain. 
And  now  for  my  story. 

At  the  age  of  24  I  had  finished  my  medical  and  hospital 
courses  and  was  ready  to  begin  my  career.  My  plans  had 
long  been  formed  with  reference  to  entering  the  army  as  a 
surgeon;  the  decision  having  been  made  for  two  reasons,  first 
as  a  matter  of  predilection;  secondly,  for  lack  of  means  to 
sustain  me  during  the  time  usually  required  to  establish  a 
private  practice. 

Then  a  tragedy  occurred  that  blasted  my  hopes  for  the  army 
and  altered  my  entire  future. 

The  examinations  were  scheduled  for  the  late  spring;  in 
January  I  had  come  down  from  my  home  in  New  England 
to  New  York  to  complete  some  clinical  work.  Generally,  I 
was  in  bad  shape,  and  about  that  time  I  began  having  attacks 
very  suspicious  of  angina  pectoris.  Finally  I  consulted  a  great 
specialist,  who  after  thorough  and  repeated  examinations, 
frankly  told  me  that  from  overwork  and  long  hours  of  study 
my  heart  had  become  enlarged  and  badly  disordered  function- 


142         THE  NARCOTIC  DRUG  PROBLEM 

ally  —  that  I  need  never  hope  to  pass  the  physical  examination 
required  for  entrance  to  the  army.  He  prescribed  rest  and 
freedom  from  care  —  two  remedies  entirely  beyond  my  reach. 

It  was  then  that  I  went  to  a  far  distant  city  in  the  West  to 
begin  my  career  on  a  small  amount  of  borrowed  capital.  It 
would  be  useless  to  dwell  upon  my  struggles,  hampered  as  I 
was  by  lack  of  funds  and  ill  health,  but  in  due  time  I  became 
established.  During  the  first  few  years  my  heart  attacks  were 
infrequent,  but  as  work  increased  they  returned,  especially 
after  an  attack  of  typhoid  fever  which  left  my  heart  in  a  most 
disturbed  state.  Naturally,  all  remedies  were  tried  with  an 
occasional  rest,  but  to  no  avail.  One  night  after  a  very 
trying  day  I  was  called  to  an  obstetrical  case ;  while  hurriedly 
dressing  I  felt  the  premonitory  sjrmptoms  of  a  heart  attack; 
it  was  then  in  a  state  of  desperation  T  took  my  first  hypoder- 
mic. The  attack  was  aborted,  but  the  next  day  I  was  des- 
perately sick.  I  may  here  add  that  at  no  time  did  I  ever 
experience  any  of  the  ecstatic  sensations  described  by  some 
from  a  dose  of  morphine  —  it  steadied  my  heart,  but  for  some 
time  after  it  was  followed  by  a  general  malaise. 

My  obstetrical  work  increased  rapidly  and  I  frequently 
found  it  necessary  to  resort  to  the  one  remedy  that  proved 
efficacious.  As  was  natural  the  time  came  when  I  found  that 
the  daily  necessity  had  become  fijxed. 

Having  been  taught  that  it  was  only  a  habit  that  required 
self  will  and  force  of  character  to  abandon  —  both  of  which  I 
knew  I  possessed  —  I  was  not  particularly  worried,  as  I  had 
planned  a  long  vacation  when  summer  came,  which  I  would 
devote  to  the  accomplishment  of  my  purpose.  But  for  certain 
unavoidable  reasons  the  vacation  became  impossible,  and  the 
next  winter  found  me  with  added  responsibilities. 

During  all  this  time  I  had  constantly  struggled  against 
the  increase  of  the  drug.  If  under  great  pressure  I  was 
obliged  to  take  an  additional  amount,  as  soon  as  it  was  over  I 
began  to  reduce.  There  were  occasions  when  I  succeeded  in 
taking  only  a  fraction  of  my  accustomed  dose,  but  if  a  call 
came,  I  was  either  obliged  to  refuse  it,  or  resort  to  the  needle. 

While  naturally  I  had  taken  no  one  into  my  confidence, 
the  habit  had  been  so  insidious  and  gradual  that  I  had  failed 


APPENDIX  143 

to  realize  how  necessary  it  was  that  it  shoiild  not  be  suspected. 
I  did  not  consider  myself  an  addict  and  only  awaited  a  pro- 
pitious occasion  to  relieve  myself  of  it,  but  that  winter  I  awoke 
to  the  realization  that  some  radical  step  must  be  taken  or  my 
professional  reputation  would  be  damaged. 

In  the  midst  of  this  perplexity  I  developed  an  attack  of  la 
grippe  and  judging  from  past  experience  I  felt  that  I  would 
be  confined  to  the  house  for  some  time,  so  resolved  to  take 
advantage  of  the  enforced  rest  and  abandon  the  use  of  the 
drug. 

It  was  a  hazardous  and  probably  unwise  decision,  but  I 
reasoned  it  was  for  the  best.  At  the  end  of  three  weeks,  after 
days  and  nights  of  physical  and  mental  torture,  I  was  able 
to  leave  my  bed,  freed  from  the  specter  that  had  haunted  me, 
but  for  the  time  a  wretched  t3rpe  of  humanity.  Four  weeks 
of  rest  in  the  country  enabled  me  to  return  to  my  practice, 
and  although  the  heart  attacks  mercifully  remained  in  abey- 
ance, it  was  only  by  sheer  force  of  will  that  I  could  accomplish 
my  routine  work,  resting  every  spare  moment  that  was  af- 
forded me,  often  refusing  calls. 

At  the  end  of  six  months  my  work  had  so  increased  that 
the  heart  symptoms  began  to  trouble  me.  The  situation  was 
desperate.  Besides  a  wife  and  two  children  depending  upon 
me  I  had  other  obligations,  and  was  still  in  debt  from  my 
illness.     I  was  unfitted  for  any  other  form  of  business. 

I  shall  not  enter  into  a  discussion  of  the  ethics  of  my  act, 
but  after  sleepless  nights  of  deliberation  I  reached  the  d^ecision 
to  return  to  the  remedy  that  alone  would  enable  me  to  at- 
tend to  my  duties,  knowing  all  that  it  involved,  but  hoping 
that  by  constant  vigilance  to  lessen  the  baneful  effects  of  the 
drug  until  some  day  when  I  should  be  free  to  leave  off  work 
and  again  be  cured. 

During  the  years  that  followed,  this  object  was  ever  before 
me,  always  fighting  against  an  increase,  devoting  my  vaca- 
tions always  to  the  same  cause.  In  a  measure  I  succeeded.  I 
never  progressed  to  extremely  large  doses,  and  I  watched  for 
and  combatted  any  possible  symptoms  of  peculiarity  or  degen- 
eration that  are  supposed  to  obtain  with  the  addict.  I  felt 
no  sense  of  moral  inferiority  or  degradation,  nor  did  I  deplete 


144f         THE  NARCOTIC  DRUG  PROBLEM 

my  strength  with  useless  anticipation  of  dreaded  possibilities. 
I  would  do  all  that  lay  in  my  power  to  preserve  myself  and 
the  future  lay  in  the  hands  of  fate. 

During  these  years  success  came  to  me.  My  clientele  grew 
both  in  size  and  character.  Positions  of  trust  were  conferred 
upon  me,  such  as  the  examinership  for  some  of  the  most  im- 
portant insurance  companies,  presidency  of  the  County  Med- 
ical Society,  etc.  I  was  elected  visiting  physician  to  two  of 
our  largest  hospitals,  and  for  some  years  did  special  work  for 
the  federal  government,  the  nature  of  which  for  obvious 
reasons  I  do  not  care  to  mention. 

In  mentioning  these  facts,  I  do  so  with  no  vainglorious  idea 
of  boasting,  but  simply  to  record  the  history  of  my  career. 
At  the  same  time  I  used  sometimes  to  ponder  over  the 
anomaly  of  my  position  —  realizing  with  what  horrified 
promptness  the  public  would  strip  me  of  my  honors,  and 
transform  its  patronage  and  good  will  to  contempt  and  pity, 
if  it  suspected  the  truth,  although  from  its  continued  patron- 
age my  work  was  evidently  entirely  satisfactory.  Even  my  in- 
timate friends  would  shrink  from  me  if  the  truth  were  known. 
Yet  my  philosophy  and  natural  optimism  sustained  me. 

It  was  at  the  end  of  about  fifteen  years  that  my  circum- 
stances were  such  that  I  felt  in  position  to  leave  off  work 
and  take  the  long  anticipated  ^^cure.^'  The  institution  se- 
lected was  one  whose  methods  seemed  most  reasonable.  I 
stated  to  the  specialist  that  I  was  anxious  to  be  cured  as 
rapidly  as  possible,  and  was  willing  to  undergo  whatever  was 
necessary,  to  the  limit  of  my  endurance. 

The  three  weeks  that  followed  I  remember  as  a  horrid  night- 
mare of  mental  and  physical  agony.  The  method  was  not 
intended  to  be  harsh,  and  the  physician  was  well-intentioned, 
though  far  from  scientific. 

In  my  desire  for  rapid  recovery  I  overestimated  my  powers 
of  endurance  and  my  nervous  system  sustained  a  shock  from 
which  it  has  never  recovered,  but  I  persisted,  with  the  as- 
sistance of  my  wife  who  remained  with  me  and  without  whose 
assistance  T  should  have  lost  my  reason. 

When  T  left  the  sanitarium  T  was  no  longer  an  "  addict,"  but 
a  wretched  neurasthenic.     Naturally  the  possibility  of  return- 


APPENDIX  145 

ing  to  my  practice  in  this  condition  was  not  to  be  thought  of 
so  I  began  making  plans  to  spend  the  winter  in  southern  Cali- 
fornia. Here  again  the  fates  interposed.  It  was  the  autumn 
when  the  sudden  financial  panic  swept  the  country,  wrecking 
the  fortunes  of  so  many  and  tying  up  the  resources  of  so 
many  others.  I  was  among  the  latter.  There  was  nothing 
for  me  to  do  but  to  return  to  practice  which  I  did  after  a 
further  rest  of  six  weeks  —  I  need  not  add  that  in  a  short 
time  I  was  again  depending  upon  the  drug  to  sustain  me  in 
the  work  that  I  was  obliged  to  resume. 

During  the  next  five  years  I  directed  every  energy  towards 
shaping  my  affairs  with  the  one  end  in  view  —  that  of  retiring 
from  practice  and  getting  permanently  well.  By  this  time 
my  two  sons  had  finished  their  education  and  were  established. 
My  income  was  sufficient  to  provide  us  with  the  comforts,  if 
not  the  luxuries  of  life.  So  with  a  heavy  heart,  but  with  a 
feeling  of  gratification,  I  abandoned  the  practice  that  I  had 
acquired  and  sustained  through  so  many  years  of  bitter  and 
sometimes  heart-rending  struggles. 

My  hopes  for  speedy  restoration  were  doomed  to  disappoint- 
ment. I  should  have  realized  that  when  release  suddenly 
came  from  the  long  years  of  daily  combat  with  so  powerful 
an  antagonist,  a  decided  reaction  must  be  the  natural  sequence. 
It  came  in  the  form  of  an  almost  complete  prostration,  that 
only  by  force  of  will  prevented  from  permanently  overcoming 
me;  but  more  than  two  years  elapsed  before  I  felt  equal  to 
the  effort  of  again  submitting  myself  to  treatment. 

This  time  I  selected  a  well-known  specialist  in  the  Middle 
West.  I  bared  my  entire  life  to  his  scrutiny,  placing  myself 
absolutely  in  his  hands.  Forty-eight  hours  as  an  inmate  of 
the  institution  convinced  me  that  I  had  made  an  unfortunate 
selection ;  but  from  a  sense  of  false  pride  at  being  a  "  quitter  ^^ 
and  a  belief  in  my  own  powers  I  remained.  The  methods 
were  absolutely  crude  and  unscientific,  the  food  poor  and  un- 
suitable, and  the  entire  environment  unfitted  to  the  well  being 
of  such  patients  as  I  was. 

At  the  end  of  seven  weeks  I  was  visited  by  the  one  most 
interested  in  me,  who  took  me  from  my  bed,  from  which  I 
could  not  have  arisen  without  assistance,   and  brought  me 


( 


146    THE  NARCOTIC  DRUG  PROBLEM 

East.  It  is  true  that  the  amount  of  the  drug  that  I  had  been 
taking  had  been  reduced  to  a  very  small  amount^,  but  at  the 
expense  of  a  badly  shattered  nervous  system  which  required 
many  months  to  regain  even  its  partial  normal  status. 

This  fall  I  am  in  New  York  and  have  placed  myself  under 
the  care  of  a  physician  who,  while  not  claiming  to  be  a 
specialist  has,  in  my  opinion  and  the  opinion  of  many  others, 
the  clearest  conception  of  the  meaning  of  drug  addiction  and 
its  pathology.  His  opportunities  for  the  study  of  these  cases 
have  been  most  imusual.  His  methods  are  both  humane  and 
scientific.  Through  him  I  have  the  hope  that  should  time  be 
allowed  me  I  shall  when  I  am  summoned  to  the  great  un- 
known, be  freed  from  the  chains  that  so  long  oppressed  but 
failed  in  the  end  to  overwhelm  me  and  compass  my  ruin. 

Drug  Addiction  from  the  Vievtpoint  of  an  Afflicted 

Physician 

By  a  Peominent  Medical  Man,  Formeely  a  Health  Officla.l  of 

An  American  City 

Maximum  efficiency  of  every  individual  member  of  this 
nation  is  necessary  today  as  never  before  in  its  history. 
Hence  any  condition  responsible  for  lessened  efficiency  on 
the  part  of  thousands  of  citizens  is  a  thing  to  be  seriously 
considered,  especially  when  among  these  are  to  be  found  a 
large  proportion  of  men  and  women  who  would  otherwise  be 
useful  workers  in  every  important  field  of  activity. 

Addiction  to  narcotic  drugs  is  today  depriving  the  country, 
either  wholly  or  partially,  of  the  services  of  thousands  of  in- 
dividuals who  but  for  this  handicap  would  be  entirely  fit 
(many  of  them  preeminently  so)  for  work  of  the  utmost  im- 
portance. This  is  a  problem  of  the  first  magnitude  and  one 
which  will  have  to  be  solved  largely  by  the  medical  profession. 

But  the  medical  profession  as  a  whole  is  utterly  lacking 
at  the  present  time  in  such  knowledge  of  addiction  as  is  needed 
'  to  enable  them  to  attack  the  pro1)lem.  For  these  reasons  I 
feel  it  to  be  my  duty  to  do  my  "bit"  as  a  medical  man,  to 
put  on  record  some  of  the  lessons  which,  from  years  of  per- 
sonal experience,  I  have  learned  as  to  addiction  itself,  and  the 


APPENDIX  147 

methods  of  treatment  with  which  I  have  had  experience  in  my 
efforts  to  be  cured. 

The  subject  is  too  important  to  excuse  anything  but  the 
utmost  frankness  in  speaking  of  the  serious  misconception 
which  medical  men  only  too  generally  share  with  the  masses 
in  regard  to  the  subject  of  addiction.  Unless  the  profession 
realizes  its  own  ignorance,  all  point  will  be  taken  from  the 
appeal  which  I  wish  to  make  to  the  physicians  of  this  country 
to  lose  no  time  in  equipping  themselves  to  deal  adequately 
with  this  great  problem. 

It  may  well  be  imagined  that  the  task  which  I  have  thus 
set  myself  is  no  easy  one,  viewed  from  any  one  of  half  a  dozen 
angles.  Yet,  if  I  am  correct,  in  believing  that  I  can  thereby 
make  a  small  contribution  to  the  cause  which  now  means  so 
much  to  all  of  us,  I  must  do  so  regardless  of  every  difficulty. 

Addiction  with  me  goes  back  a  number  of  years,  covering 
in  fact,  almost  my  entire  career  as  a  physician.  During  this 
entire  time,  as  will  be  more  fully  referred  to,  I  have  tried 
cure  after  cure,  besides  having,  time  and  again,  sought  by 
own  efforts  to  rid  myself  of  this  burden.  I  have  naturally 
during  these  years  studied  and  thought  much  about  the  prob- 
lem which  has  meant  so  much  to  me.  All  this  by  way  of 
showing  wh}^  I  believe  that  my  experiences  and  opinions 
should  have  some  value. 

First  of  all,  let  it  be  clearly  understood  that  the  addiction 
which  I  shall  discuss  is  limited  strictly  to  opium  and  its 
derivatives ;  first,  because  my  own  experience  is  limited  to  this 
group  and,  second,  because  much  that  I  shall  have  to  say 
does  not  apply  to  all  so-called  habit-forming  drugs  to  an  equal 
extent,  and  to  some  of  them  not  at  all.  Addiction  as  thus 
limited  is  as  true  a  disease  as  any  with  which  the  human  body 
is  afflicted. 

To  look  on  the  opium  addict  as  a  man  with  a  vicious  habit 
which  he  could  quit  if  only  he  truly  cared  to  do  so  displays 
a  profound  misunderstanding  of  plain  facts.  As  well  claim 
that  a  man  with  typical  malarial  infection  has  simply  be- 
come so  accustomed  to  having  chills  and  fever  at  a  given 
hour  on  certain  days  that  when  this  hour  arrives  he  quakes 
through  mere  habit  as  to  claim  that  the  equally  characteristic 


148         THE  NARCOTIC  DRUG  PROBLEM 

and  even  more  pronounced  and  distressing  symptoms  which 
manifest  themselves  when  the  addict  is  deprived  of  his  drug 
are  due  to  habit,  that  is,  to  "  a  condition  which  by  repetition 
has  become  spontaneous/^ 

We  would,  as  a  matter  of  fact,  be  less  absurd  in  the  former 
instance  than  in  the  latter;  for  we  could  argue  the  case  out 
with  our  malarial  friend,  telling  him  he  could  conquer  his 
'^  habit "  by  the  exercise  of  will  power,  and  —  provided  we 
argued  long  enough  —  we  might  convince  ourselves  that  we 
were  right  because  he  would  cease  to  shake,  his  fever  would 
subside  and  until  the  next  crop  of  parasites  was  turned  loose 
in  his  blood  stream,  he  would  to  all  intents  and  purposes  feel 
a  well  man,  while  in  the  latter  case  the  more  we  talked  of 
habit  —  that  is,  the  longer  the  addict  was  deprived  of  his 
dose  —  the  plainer  would  become  the  picture  of  a  disease- 
racked  body  and  a  tormented  mind. 

I  do  not,  of  course,  mean  to  offer  the  above  comparison  as 
either  perfect  in  itself,  or  as  sufficient  to  establish  the  claim 
that  addiction  is  a  true  disease.  The  fact  that  it  is  a  disease 
has  impressed  itself  on  all  competent  observers  of  a  sufficient 
number  of  cases,  and  must  be  accepted.  Yet  it  is  astonishing 
to  find  that  many  educated  physicians  do  not  know  this, 
while  an  even  larger  number,  though  readily  admitting  that 
addiction  is  a  disease,  nevertheless  show,  both  by  their  manner 
of  discussing  the  subject  and  by  their  attitude  towards  addicts 
seeking  their  advice,  that  this  is  little  more  than  a  verbal 
concession  on  their  part. 

If,  however,  it  be  argued  that  the  contention  as  to  addiction 
being  a  disease  is  vitiated  by  the  fact  that  an  occasional  addict 
stops  taking  his  drug  by  "  will  power,"  that  is,  without  taking 
treatment,  we  can  point  to  an  even  larger  proportion  of  mild 
cases  of  malarial  fever  in  which  spontaneous  cure  has  come 
about.  But  this  does  not  prove  that  thc^  one,  any  more  than 
the  other,  is  not  a  disease. 

Indeed,  there  could  be  no  stronger  argument  in  favor  of 
the  fact  that  addiction  is  an  actual  disease  than  the  very 
phenomena  presented  by  the  occasional  addict  who  stops  tak- 
ing the  drug  by  "  will  power."  Neither  medical  writers  nor 
literary   geniuses,   whether   themselves   addicts   or   mere   ob- 


APPENDIX  149 

servers,  have  yet  succeeded  in  presenting  a  true  picture  of  the 
tortures  which  this  involves.  There  could  be  no  greater  error 
than  to  regard  cure  as  dating  from  the  time  the  last  dose 
was  taken.  When,  in  these  cases,  cure  comes  at  all,  it  is 
only  after  weeks,  or  months,  of  horrible  existence,  during 
which  kind  nature  brings  about  a  more  or  less  complete 
restoration  of  body  and  mind  not  alone  from  the  disease  of 
addiction,  but  also  from  the  profound  shock  of  unskilled  or 
unwise  withdrawal.  Will  power  has  enabled  the  addict 
to  abstain  from  taking  the  drug,  while  nature  cured  the  dis- 
ease. 

There  has  been  no  time  during  all  the  years  of  my  addiction 
that  I  have  not  earnestly  longed  to  be  free  from  its  clutches. 
This  is  sufficiently  proved  by  the  many  efforts  which  I  have 
made  to  find  a  cure,  each  time  at  great  personal  sacrifice  and 
expense,  each  time  only  to  have  my  hopes  shattered,  after  un- 
told suffering  and  fresh  disillusionment. 

But  a  real  cure  I  have  thus  far  been  unable  to  find.  I  have 
tried  everything  that  seemed  to  offer  a  chance:  gradual  re- 
duction, self-conducted  and  at  institutions,  the  Keeley  cure 
several  times,  and  since  then  all  of  the  vaunted  cures,  as  each 
appeared  in  turn,  advocated  by  men  of  high  standing  in  the 
medical  profession.  Concerning  this  last  class,  I  have  each 
time  hoped  that  such  men  could  not  be  totally  in  error  as  to 
the  practical  results  of  their  methods,  notwithstanding  what 
has  seemed  to  me  the  most  bizarre  pathology  on  which  they 
have  claimed  these  methods  to  be  based. 

I  might,  perhaps,  have  been  warned  by  certain  palpable 
danger  signs,  but  I  have  been  too  anxious  to  find  the  cure. 
I  cared  not  at  all  how  mistaken  their  pathology ;  for  I  could 
not  believe  that  men  of  such  standing  could  be  equally  mis- 
taken as  to  the  success  or  failure  of  what  went  on  under  their 
very  eyes. 

And  right  here  let  me  set  down  what  has  impressed  me  as 
inexcusable  neglect  of  these  cases  by  most  of  these  self  same 
"big'^  men  of  the  medical  profession.  One  after  another  I 
have  found  physicians  who  receive  and  undertake  to  treat 
cases  of  addiction  brought  to  them  by  the  lure  of  high  pro- 
fessional reputation  and  medical  articles  in  which  is  painted 


150         THE  NARCOTIC  DRUG  PROBLEM 

a  glowing  picture  of  some  new  and  wonderful  cure.  And, 
one  after  another,  I  have  found  these  men  of  high  professional 
standing  giving  to  their  cases  not  even  enough  time  and  atten- 
tion to  enable  them  to  form  an  intelligent  opinion  as  to  their 
condition  and  progress,  much  less  what  would  be  needed  for 
the  proper  stud}^  and  treatment  of  one  of  the  most  difficult 
and  distressing  ailments  which  afflict  mankind. 

Moreover,  comparing  notes  with  medical  men  who  have 
been  fellow  patients  under  similar  circumstances  (many  of 
them,  I  may  remark,  of  the  highest  type,  as  men  and  as 
physicians),  there  has  been  among  us  a  universal  sense  of 
shame  and  indignation  that  men  with  such  reputation  and 
standing  should  lay  the  medical  profession  open  to  the  justly 
founded  criticism  of  extortion  and  neglect  of  duty,  frequently 
of  seemingly  rank  commercialism,  even  including  the  splitting 
of  fees  with  quacks  and  charlatans  of  the  worst  sort. 

In  saying  that  I  have  found  no  cure,  I  do  not  mean  that 
I  have  never  succeeded  in  getting  to  the  point  where  I  could 
get  along  for  shorter  or  longer  periods  without  the  drug. 
Many  times  I  have  succeeded  by  myself  in  gradually  reducing 
the  dose  to  a  minimum  and  then  making  the  final  plunge 
and  taking  none  at  all  for  some  time.  What  this  has  meant 
I  will  not  undertake  to  describe.  Several  times  I  have  man- 
aged to  keep  from  using  the  drug  for  a  while  after  taking 
treatment  of  one  kind  or  another.     But  have  I  been  cured  ? 

Let  no  one  thoughtlessly  reply  that  the  very  fact  of  my 
having  on  each  of  these  occasions  reached  a  point  where,  ac- 
cording to  my  own  statement,  I  was  able  to  live  without  the 
drug,  constitutes  proof  that  I  was  cured,  or  that  when  I  started 
to  use  it  again  I  was  merely  yielding  weakly. 

What  has  actually  happened  has  been  this.  Each  time 
that  I  have  succeeded,  in  one  way  or  another,  in  reaching  a 
point  where  I  was  no  longer  taking  the  drug,  I  have,  even 
while  the  suffering  was  still  acute,  been  filled  with  a  sense  of 
happiness  and  hope  that  enabled  me  to  stand  it  thankfully. 
I  have  argued  with  myself  that,  being  then  able  even  to  exist 
without  the  drug  and,  for  a  while  finding  this  existence  day 
by  day  a  little  less  of  torture,  I  might  reasonably  hope  for 
continued  improvement.     I  have  not  expected  miracles,  but  I 


APPENDIX  151 

have  felt  that  each  week  should  be  easier,  until,  after  a  period 
of  some  few  months,  I  should  again  be  normal. 

But  this  has  not  come  about.  Always  I  have  reached  a 
point  where  progress  seemed  to  stop,  and  beyond  this  point 
my  system  refused  to  react.  Occasionally  this  standstill  has 
been  quickly  reached,  that  is,  I  could  not  react  beyond  a  point 
where  I  was  unable  to  sleep,  where  my  legs  ached  atrociously, 
and  where  I  was  so  completely  unstrung  that  life  was  unen- 
durable. At  best,  progress  has  continued  for  a  few  weeks, 
after  which,  though  resting  well,  having  a  prodigious  appetite 
and  not  undergoing  marked  physical  suffering,  I  have  actually 
been  far  from  normal.  This  was  shown,  on  these  special 
occasions,  chiefly  by  my  inability  to  do  satisfactory  work,  by 
my  tiring  altogether  too  easily  and  by  a  general  feeling  of 
unrest  and  disquietude. 

I  realize  the  difficulty  of  so  describing  my  condition  during 
these  most  favorable  occasions  as  to  show  at  all  convincingly 
that  I  was  not  actually  cured  and  that,  in  consequence,  my 
resuming  the  taking  of  the  drug  was  anything  but  a  relapse. 
This,  however,  I  must  not  attempt  to  do,  since  the  main  con- 
tention which  I  wish  to  make  is  here  directly  led  up  to. 

And,  hard  as  is  the  whole  task  I  have  set  myself  in  writing 
this  account,  this  special  part  of  it  is  peculiarly  difficult,  in- 
volving the  risk  of  appearing  to  set  a  false  value  on  certain 
personal  considerations. 

My  life  has  been  an  active  and  useful  one.  I  have  done 
work  which  I  know  to  be  good  and  which  has  brought  recogni- 
tion. Successful  work,  even  in  a  given  line  of  endeavor,  is 
not  always  due  to  the  same  qualities  in  different  men.  My 
own  work  has  been  characterized  by  the  exercise  of  careful 
judgment  and  the  power  of  accurate  analysis,  qualities  which 
I  have  always  been  credited  with  possessing.  Now,  after 
the  most  favorable  of  the  so-called  treatments  which  I  have 
taken,  and  after  allowing  considerable  time  for  complete  re- 
covery, I  have  in  no  instance  regained  these  most  essential 
requisites  for  my  work,  and  thus  I  have  been  placed  in  a 
position  where  I  would  either  have  had  to  discontinue  my 
work,  or  else  do  the  only  thing  v^hich  made  the  resuming 
of  that  work  possible.     And  always  there  has  been  the  absolute 


152    THE  NARCOTIC  DRUG  PROBLEM 

conviction  that  this  state  of  affairs  was  due  to  my  not  having 
been  actually  cured.  On  this  point  there  has  not  been  one 
iota  of  doubt. 

Perhaps  if  I  had  been  able  at  such  times  to  take  a  complete 
rest  of  six  months  or  even  a  year,  I  might  have  been  fully 
restored,  but  this  has  not  been  possible.  I  have  not  been 
able  to  remain  away  from  work  for  over  five  or  six  weeks 
after  the  "  cure  ^^  proper,  and  even  this  has,  as  may  well  be 
understood,  been  a  severe  drain,  when  I  have  taken  some  cure 
or  other  at  as  short  intervals  as  I  could  manage  to  get  to- 
gether sufficient  funds  and  the  opportunity  to  leave  my  prac- 
tice. 

Of  course  it  may  be  argued  that,  rather  than  return  to 
the  use  of  the  drug  and  thus  again  be  able  to  live  a  life  as 
nearly  approaching  normal  as  is  possible  for  an  addict,  it 
would  be  better  to  refrain  from  using  the  drug,  even  though 
this  involved  never  again  being  able  to  do  those  things  which, 
to  the  ambitious  man,  are  essential  to  make  life  worth  the 
living.  I  submit  that  it  is  a  high  motive  and  not  a  low  one 
which  makes  a  man  willing  to  pay  the  price  rather  than  live 
a  vegetative  existence  when  he  knows  himself  capable  of 
better  things.  To  understand  this  point  of  view  it  must  be 
remembered  that  the  addict  gets  no  rosy  dreams,  no  wonderful 
journeys  into  a  beautiful  and  unreal  world,  no  artificially 
enhanced  powers  beyond  those  of  the  non-addict,  but  at  best 
only  such  equanimity  and  energ}^  as  are  the  latter's  happy 
possessions. 

My  point,  therefore,  is  that  my  resorting  to  the  drug  after 
having  stopped  its  use  a  number  of  times  does  not  mean  that 
I  have  many  times  been  cured,  and  many  times  relapsed,  but 
that  I  have  not  been  truly  cured.  \\Tien  the  latest  "  cure  " 
which  I  have  taken  has  left  me,  even  after  weeks,  still  suffer- 
ing acutely  and  continuously,  and  not  improving  in  the  slight- 
est so  far  as  I  could  see,  I  have  taken  the  drug  again  for 
relief  from  torture  no  longer  bearable.  After  "  cures  "  which 
have  left  me  in  decidedly  better  plight  but  in  the  intolerable 
condition  last  described  above,  and  with  progress  at  a  stand- 
still, I  have  taken  the  drug  onl}^  after  calmly  surveying  the 
situation,  and  as  the  lesser  of  two  evils. 


APPENDIX  153 

I  must  reiterate  my  strong  desire  to  find  a  cure,  a  real 
cure,  one  deserving  the  name ;  that  is,  a  cure  which  will  leave 
me  normal,  without  need  of  the  drug,  and  able  to  do  the  work 
which  I  must  do  in  the  world  unless  I  am  willing  to  be  a 
slacker.  But  until  I  can  find  such  a  cure  (and,  in  spite  of  my 
unhappy  experiences,  I  will  keep  up  the  quest)  I  would  have 
only  contempt  for  myself  as  a  physician  and  as  a  rational 
being  if  I  failed  meanwhile  to  make  the  best  compromise 
possible,  namely,  to  take  each  day,  just  as  I  would  take  thy- 
roid substance  were  I  suffering  from  hypothyroidism,  a  suf- 
ficient amount  of  morphine  to  enable  me  to  attend  to  life's 
duties  and  to  occupy  in  the  world  that  useful  place  which 
my  qualifications  enable  me  to  occupy. 

One  of  the  great  hardships  under  which  every  addict  suffers 
is  the  constant  dread  lest  his  affliction  become  known  and  he 
be  branded  a  "  morphine  fiend,''  a  term  which  should  be  pro- 
hibited, or  at  least  never  used  by  an  intelligent  physician. 
What  this  exposure  would  mean  to  a  man  of  standing  in  his 
community  I  need  not  explain.  This  risk  he  must  always 
run,  but  it  would  be  robbed  of  some  of  its  terror  if  the  nature 
of  addiction  were  better  understood. 

Therefore  the  law  now  existing  in  some  states  requiring 
the  registration  of  addicts  is  little  short  of  barbarous.  So 
little  possible  good  can  be  accomplished  by  this  law  that  one 
is  tempted  to  believe  that  its  passage  was  not  instigated  pri- 
marily by  honest,  though  misguided  zealots  but  by  quite  an- 
other class.  The  addict,  in  his  efforts  to  find  a  cure,  has 
learned  something  of  a  class  of  men,  who,  posing  as  public 
benefactors,  are  in  reality  a  shrewd  set  of  rascals,  capitalizing 
the  misfortunes  of  the  addict  most  successfully.  If  such  men 
were  not  the  originators  of  the  idea  of  registration,  certainly 
they,  and  not  the  body  politic,  are  its  chief  beneficiaries,  since 
it  affords  them  an  authentic  list  of  prospective  victims. 

As  for  the  effect  of  this  law  on  the  addict,  it  merely  adds 
further  to  his  dread  of  exposure.  Think  of  the  position  of  a 
man  of  prominence  and  respected  in  his  community,  having 
his  own  feelings  as  have  other  men,  holding  equally  dear  the 
sensibilities  of  those  he  loves,  living  under  the  constant  dread 
that  his  necessities  may  any  day  force  him  to  seek  aid  in  a 


154.         THE  NARCOTIC  DRUG  PROBLEM 

;  state  in  which  his  name  will,  as  it  were,  be  added  to  a  rogues' 
gallery ! 

My  plea  is  for  realization  of  the  great  need  for  finding 
some  means  whereby  the  individual  addict  may  get  real  relief 
and  whereby  addicts  collectively  may  be  restored  to  such  con- 
dition as  will  render  them  capable  of  performing  those  services 
of  which  our  country  is  now  in  need. 

I  am  confident  that  I  am  understating  the  case  when  I 
say  that  nine  addicts  out  of  ten  earnestly  desire  to  be  cured. 
Why  should  they  not?  They  get  no  pleasure  out  of  taking 
the  drug,  but  only  relief  from  intolerable  suffering  which  they 
must  otherwise  endure.  Hence  to  be  free  both  from  this 
suffering  and  from  the  necessity  of  getting  this  relief  by 
artificial,  and  at  present  exceedingly  costly,  means  is  bound 
to  appeal  to  them.  Most  addicts,  I  am  confident,  are  willing 
to  go  through  whatever  acute  suffering  may  be  involved  in  any 
really  rational  treatment  which  will,  after  a  reasonable  time, 
restore  them  to  normal  condition. 

Experiences  such  as  I  have  described  above  are,  I  know, 
the  rule  and  not  the  exception  with  those  who  have  tried  the 
various  so-called  cures.  They  can  hardly  be  called  satisfac- 
tory. Even  admitting  that  they  may  prove  successful  in  a 
small  proportion  of  cases,  relatively  few  addicts  are  able  to 
find  the  means  of  taking  them,  such  as  I  have  been  able  to 
make  for  myself  in  the  midst  of  a  very  active  life. 

Surely  a  disease  having  so  definite  a  symptomatology  and, 
I  believe,  so  plain  a  pathology,  must  be  susceptible  of  rational 
cure.  That  such  a  cure  has  not  yet  been  found  by  those  who 
so  loudly  proclaim  to  have  found  one  I  honestly  believe. 
Whether  others  have  devised  more  promising  lines  of  treat- 
ment I  frankly  do  not  know. 

But  a  cure  must  be  found  which  does  more  than  any  I  have 
succeeded  in  finding.  In  what  other  disease  would  a  patient 
who,  after  reaching  a  certain  point,  beyond  which  he  could 
not  progress  towards  recovery,  be  told  that  from  then  on 
everything  rested  with  him,  although  he  himself  knew  that  his 
need  for  help  was  really  as  great  as  it  ever  was?  In  what 
other  disease  would  any  physician  worthy  of  the  name  calmly 
tell  a  patient  that,  having  taken  a  "  cure,^'  he  was,  ipse  facto, 


APPENDIX  155 

cured,  and  become  highly  incensed  when  the  patient  pleaded 
that  his  condition  was  in  many  respects  more  desperate  than 
before  treatment  ? 

The  medical  profession  must  seriously  study  addiction.  Of 
material  there  is,  unfortunately,  an  abundance.  Some  high 
authority  should  see  that  every  facility  is  afforded  the  proper 
persons  for  employing  it.  It  is  not  unlikely  that  many  of  the 
"  cures  "  which  have  been  advocated  have  in  them  some  ele- 
ments of  good,  properly  selected  and  properly  applied  in  each 
individual  case.  Possibly  competent  investigation,  furnished 
with  every  facility,  might  result  in  the  discovery  of  a  truly 
specific  cure.  I  have  long  thought  that  there  was  such  a 
possibility  in  more  than  one  direction,  but  investigation  of 
these  would  involve  very  careful  and  laborious  work,  as  well 
as  considerable  cost.  Here  indeed^  would  seem  to  be  a  won- 
derful opportunity  for  philanthropy. 

But  while  such  a  specific  cure  would  be  an  untold  blessing, 
we  need  not  find  one  in  order  to  meet  the  situation  —  at 
least,  much  more  successfully  than  it  is  being  met  at  present. 
Coordination  of  the  entire  problem  of  addiction,  in  the  hands 
of  the  few  men  whose  work  in  this  field  is  most  promising 
(and  the  men  I  have  in  mind  are  not  those  with  whose 
vaunted  cures  I  have  had  such  unhappy  experiences)  would 
almost  certainly  lead  to  valuable  results. 

While  every  effort  should  be  exerted  to  determine  the  best 
lines  of  treatment,  meanwhile  there  is  a  great  deal  which 
should  be  done  in  other  directions.  Let  the  medical  profes- 
sion help  in  bringing  about  better  understanding  of  addiction 
—  first,  of  course,  learning  this  themselves.  Until  the  addict 
can  be  offered  rational  treatment,  the  profession  should  do 
what  it  can  in  making  the  lives  of  addicts  less  unbearable  by 
removing  from  the  public  mind  some  of  the  gross  miscon- 
ceptions concerning  addiction,  seeing  to  it,  especially,  that 
these  unfortunates  are  not  stigmatized  as  "  morphine  fiends  ^' 
and  that  they  are  given  the  means  of  obtaining,  without  risk 
and  hardship  and  almost  prohibitive  cost,  the  supply  of  their 
drug  which,  until  they  are  cured,  is  to  them  as  necessary  as 
the  air  they  breathe. 

But  IJie  finding  of  a  real  cure  or  treatment  —  not  neces- 


156         THE  NARCOTIC  DRUG  PROBLEM 

sarily  specific,  not  a  thing  to  be  applied  indiscriminately  in 
every  case,  but  a  rational  method  of  handling  addiction  as 
other  well  known  diseases  are  handled  —  is  the  great  aim, 
or,  if  it  be  that  sufficient  is  already  known  by  some  men  in 
the  profession  as  to  the  rational  handling  of  addicts,  let 
these  men  be  found  and  their  services  subsidized  by  the  gov- 
ernment and  used  to  the  fullest  extent,  in  teaching  others,  and 
these  still  others,  until  there  is  built  up  a  system  extending 
over  the  entire  country,  capable  and  equipped  for  giving  to 
every  addict  the  opportunity  for  cure.  This  is  a  crying  need 
ia  our  country  today.  Surely  there  must  be  somewhere  recog- 
nition of  this  fact  and  resources  enough  to  make  it  possible 
for  this  need  to  be  supplied. 

A  Plea  for  the  Broader  Consideration"  of  ISTarcotic 
Drug  Addiction  by  the  Medical  Profession 

By  a  Peacticing  Physician  Who  Has  Met  the  Problem  in 
His  Own  Family 

In  view  of  a  recent  experience  of  mine  in  seeking  intel- 
ligent medical  help  for  a  near  relative  whom  I  learned  was 
a  narcotic  drug  addict,  I  take  pleasure  in  recounting  experi- 
ences of  the  past  few  months  in  the  handling  of  such  a  case, 
and  in  calling  attention  to  the  conditions  which  my  investiga- 
tions have  shown  me  to  exist  in  our  profession. 

My  line  of  professional  activity  had  not  brought  me  know- 
ingly into  touch  with  narcotic  drug  addiction,  and  I  enter- 
tained the  prevailing  medical  opinions  in  regard  to  it. 

About  five  months  ago  I  received  a  letter  couched  in  apolo- 
getic language  from  a  practitioner  in  another  state  informing 
me  that  a  younger  brother  of  mine  had  been  under  his  care 
for  a  number  of  days  suffering  from  withdrawal  S5rmptoms 
occasioned  by  inability  to  purchase  morphine,  and  advising 
me  to  place  him  in  some  institution  where  he  could  be  re- 
strained. 

I  immediately  began  asking  my  colleagues  where  I  could 
send  such  a  case,  and  was  amazed  at  the  general  lack  of 
knowledge  in  regard  to  and  sympathy  for  these  unfortunates. 
In  truth  no  one  could  point  out  a  single  institution  where 


APPENDIX  167 

such  a  patient  could  be  sent  with  any  hope  that  he  might 
be  handled  in  a  humane  and  intelligent  manner. 

My  investigations  of  the  institutions  they  suggested  showed 
this  to  be  the  fact. 

Most  every  one  seems  to  regard  those  suffering  from  this 
condition  as  being  of  a  lower  order  of  humanity,  unwilling 
or  too  weak-minded  to  help  themselves  and  fit  subjects  only 
for  association  with  what  is  commonly  known  as  the  "  under- 
world.^^ I  wish  to  say  that  I  myself  have  undergone  a  very 
complete  revision  of  mind  regarding  these  cases  since  the 
case  of  my  brother  has  compelled  me  to  investigate  them. 
I  have  known  my  brother  too  well  and  for  too  many  years 
to  believe  that  he  can  possibly  be  placed  in  any  such  category. 

I  have  made  careful  inquiries  into  the  circumstances  and 
origin  of  his  addiction,  and  the  results  are  absolutely  con- 
vincing that  the  first  administrations  of  the  narcotic  were 
to  meet  therapeutic  indications  and  were  continued  without 
his  knowledge  or  appreciation  of  its  actions  or  ultimate  re- 
sults. I  know  that  he  has  never  experienced  any  pleasure 
from  the  narcotic,  and  I  know  that  when  the  condition  of 
addiction  manifested  itself  he  did  not  know  what  was  the 
matter  with  him.  He  only  knew  that  narcotic  relieved  in- 
tense suffering.  I  had  never  seen  a  case  of  addiction  to  my 
knowledge  before  I  went  to  see  him  in  response  to  the  letter 
I  received.  The  clinical  symptomatology  of  withdrawal  of  an 
opiate  was  truly  a  revelation  to  me.  That  the  condition 
from  which  these  patients  suffer  is  a  distinct  disease  cannot 
be  questioned  by  any  intelligent  observer. 

I  have  found  that  the  majority  of  patients  who  begin  the 
use  of  opiates  do  so  in  search  of  relief  from  pain,  and  are 
not  aware  of  the  fact  for  a  long  time  that  the  suffering  they 
endure  when  the  drug  is  discontinued  is  due  to  a  disease 
they  have  contracted.  Apparently  the  medical  profession  is 
also  ignorant  of  this  fact. 

A  more  pathetic  sight  I  have  never  seen  than  one  of  these 
patients  who  has  been  suddenly  deprived  of  his  medicine. 
They  will  tell  you  that  they  will  become  insane  or  be  driven 
to  suicide  if  they  cannot  obtain  relief  from  their  suffering. 
Hence  their  willingness  to  obtain  the  drug  at  any  cost.     I 


158         THE  NARCOTIC  DRUG  PROBLEM 

have  come  to  believe  that  any  man  is  justifiable  in  lying  or 
stealing  to  escape  the  agonies  I  have  witnessed. 

It  seems  a  crime  that  we  of  the  profession  have  gone  so 
long  without  any  attempt  to  study  or  understand  the  disease 
which  we  in  our  daily  rounds  are  constantly  creating.  Cer- 
tainly our  standard  medical  literature  contains  little  if  any- 
thing of  value  in  regard  to  this  condition,  and  investigation 
of  the  claims  and  procedure  of  the  widely  advertised  so-called 
"  treatments  "  and  "  cures  "  readily  convinces  one  of  their 
unworthiness. 

I  know  that  much  can  be  done  for  the  cure  of  these  patients 
by  an  intelligent  effort  on  the  part  of  the  medical  profession, 
and  a  willingness  to  open  their  minds  to  the  clinical  facts 
of  this  condition  and  to  handle  it  like  other  diseases. 

In  search  of  information  I  have  gotten  into  touch  with 
cases  of  addiction  other  than  my  brother's,  and  I  find  that 
the  majority  of  them  are  desperately  anxious  to  be  cured. 
They  tell  me,  however,  that  institutions  such  as  jails,  work- 
houses, lunatic  asylums,  alcoholic  wards  of  the  charity  hos- 
pitals, and  those  that  they  have  tried  of  the  advertised  cures 
are  places  of  insufferable  torture  from  which  they  emerge  in 
worse  condition  than  that  in  which  they  entered. 

There  are  estimated  to  be  as  many  as  500,000  or  more  ad- 
diction cases  in  the  State  of  'Rew  York  alone.  I  ask  in  all 
earnestness,  is  it  not  worth  while  to  try  to  do  something  more 
than  we  are  doing  for  these  sufferers  ? 


PRINTED   IN   THE   UNITED    STATES   OT  AMBEIOA 


INDEX 


INDEX 


Abnormalities,  getting  rid  of,  in 

preliminary  stage,  83 
Acidosis   in   opiate  addiction,  48 
Addict,  criminal  or  vicious,  han- 
dling of,  108 
drug,  as  a  surgical  and  medi- 
cal risk,  85 
cooperation  of,  72 
often    unknown    and    unsus- 
pected, 7 
honest,  and  need  of  competent 
medical  care,  109 
and  custodial  care,  28 
medical,    personal    history    of, 

140 
mixed,  115 

narcotic,     failure     to     imder- 
stand,  5 
will  cooperate  and  suffer,  6 
Addicts,  drug,   accidental  or  in- 
nocent, 28 
age  of,  24 

and   influenza    and   pneumo- 
nia, 86 
majority  of,  17 
often  understand  own  cases, 

7 
what  type  or  class  become, 
23 
innocent     and     worthy,     what 
shall   we    do    with   them? 
129 
narcotic,    average    individuals, 
3 
often    men    and    women    of 
high  ideals,  3 
worthy  and  innocent,  problem 

of,  128 
youthful,  125 
Addiction,  author's  definition  of, 
20 
beginning  stage  of,  30 
development  of,  29 

161 


Addiction    {contiwied) 

disease,    author's    conclusions, 
40 
a  chronic  condition,  93 
in  newly  born  infant,  24 
may  afflict  all  classes,  19 
mechanism  of,  36,  41 
rational  handling  of,  61 
treatment  of,  and  legitimate 
medical  practice,  99 
drug,  a  medical  problem,  28 
among  soldiers,  117 
and  defectives,  16 
a  plea  for  broader  considera- 
tion of,  156 
and  the  average  person,  17 
as  a  sequelae  of  war,  120 
contraction  of,  in  the  army, 

118 
in  surgical  cases,  85 
medical  problem  of,  21 
methods  of  treating,  50 
origin  of,  25 
so-called   specific,   treatment 

of,  55 
unsuspected,  26 
viewpoint    of    physician    af- 
flicted with,  146 
wrongly  described,  14 
established,  stage  of,  31 
narcotic,    a   demonstrable   dis- 
ease, 59 
a  recognized  menace,  4 
classed  as  a  vice  or  morbid 
appetite,  4 
opiate,  as  a  war  problem,  117 
complicated  with  cocaine,  3 
picture  wrongly  painted,  2 
Adequacy,  metabolic  and  organic, 
relation   to    other    disease 
conditions,  92 
Administration,     narcotic     drug, 
regulation  of,  65 


16a 


INDEX 


"After  Care"  or  convalescence, 
53 

Age  of  addicts,  24 

American  Medicine,  human  doc- 
uments from,  137 

Antidotal  substance,  42 

Any  one  liable  to  drug  addiction, 
8 

Attempts  at  administrative  and 
police  control,  4 

Attitude  of  drug  addict,  71 
of   lawmakers   to    drug   addic- 
tion, 102 
of  medical  profession,  50 
personal,  of  physician  to  drug 

addict,  70 
to  drug  addicts,  author's  un- 
just, 12 

Auto-intoxication   and    autotoxi- 
cosis,  46 

Balance,   drug   adequate,   impor- 
tance of  establishing  and 
maintaining,  92 
narcotic    drug,    and    minimum 
daily  need,  66 
and  operative  procedure,  92 
necessity  of  maintaining,  67 
Basis  of  success,  132 
Beacon-light    of    hope    for    drug 

addicts,  14 
Belladonna,  use  of,  55 
Bellevue  Hospital,  early  work  in 
alcoholic      and       narcotic 
wards,  2 

Care,  custodial,  and  the  honest 
addict,  28 

Cases  demonstrating  presence  of 
antidotal  substance,  43 

Catharsis,  non-irritating,  79 

Cause  of  withdrawal  symptoms, 
38 

Causes  of  failure  in  solving  drug 
problem,  5 

Clinics,    drug,    need    for,    under 
competent    medical    direc- 
tion, 124 
public,  135 


Cocaine,  habitual  use  of,  115 

Committee  appointed  by  Secre- 
tary of  Treasury,  report, 
14 

Complications,  avoided  by  intelli- 
gent patients,  78 

Conclusions  of  author,  40 

Condition,  another  disease,  rela- 
tion of  functional  balance 
to,  92 
drug  patient's,  as  index  of  suc- 
cessful treatment,  75 

Considerations,    fundamental,    1 1 

Convalescence,  and  "  after  care," 
53 

Cooperation  of  drug  addict,  fac- 
tors which  determine,  72 

Cure  of  drug  addiction.  What 
constitutes?   76 

"  Cures,"  basis  of,  55 

Custodial  care  and  the  honest 
addict,  28 

Danger  of  restrictive  legislation, 
123 

Dangers  of  belladonna,  hyoscine, 
pilocarpine,  etc.,  80 

Data,  institutional,  lack  of,  58 

Defectives  and  drug  addiction,  16 

Definition  of  term  "  narcotics," 
114 

Deprivation,  forcible,  danger  of, 
53 

Development  of  addiction  stage, 
29 

Discontinuance  of  narcotic  drug, 
difficulties  of,  69 

Disease,  addiction,  rational  han- 
dling of,  61 
drug  addiction,  nature  of,  23 

Documents,  human,  137 

Dosage,  narcotic  drug,  in  rela- 
tion to  withdrawal  symp- 
toms, 75 

Doses,  therapeutic,  and  toxic 
stage  of  normal  reaction 
to,  29 

Drug,  narcotic,  balance,  67 
definite  body  need  for,  37 


INDEX 


163 


Drugs,  narcotic,  and  the  physical 
condition   established,   21 
may  afford  pleasure,  3 
legitimate   use   of,    in   peace 

and  war,  114 
prescribing    and    dispensing 

of,  100 
relations  of  laws  to,  95 
Du  Mez's  recent  paper,  38 

Education  and  training,   131 
lay,  medical  and  ofl&cial,  need- 
ed, 109 
neglect   of,   and   illicit   traffic, 
126 
Efficiency,       functional,       nutri- 
tional  and   metabolic   im- 
portance of,  92 
Efforts,  author's  early,  11 
Elimination,       competent,       not 
measured  in  bowel  move- 
ments, 81 
of   opiate,   and   cell  tolerance, 
46 
Evils,  chief,  of  present  drug  sit- 
uation, 122 
Exploitation,  commercial,  and  its 
financial  possibilities,   125 
of  physical  suffering,  123 

Facts  concerning  drug  addiction, 
necessity      for      unbiased 
medical    investigation    of, 
101 
significant,  13 

Fear,   constant,   addict   lives  in, 
92 

Function,  inhibition  of,  46 

Gioffredi,  investigation  of,  26,  38 

Handling,  institutional  and  cus- 
todial,  and   certain   types 
of  addicts,  108 
of  criminal  or  vicious  addict, 

108 
preliminary  to  withdrawal,  62 
rational,  of  addiction  disease,  61 


Harrison  Law,  effect  on  medical 
profession,  96 
reasons  for  failure  of,  96 
wise  in  purpose,  95 
Hirschlaff's  experiments,  26,  38 
History      of      medical      addict, 

140 
Hyoscyamus,  use  of,  55 

Ignorance,  the  harmful  effects  of, 
127 

Immunity  to  narcotic  drugs,  4 

Inefficiency,  medical,  6 

Infant,  newly-born,  and  addic- 
tion disease,  24 

Influenza  and  pneumonia  in  drug 
addicts,  86 

Information,  clinical,  paucity  of, 
58 

Intervals,  long,  between  doses, 
desirable,  77 

Introduction,  1 

Jennings'  studies  of  acidosis,  48 

Kobert's  and  Toth's  studies,  38 

Law,  Harrison,  failure  of,  96 
makers,   attitude   to  drug  ad- 
diction, 102 
What  has  it  done  for  the  ad- 
dict?  102 
Laws     and    old     conceptions    of 
drug  addiction,  96 
and  their  relations  to  narcotic 

drugs,  95 
drug,     enforcement     and     in- 
creased   suffering    of    ad- 
dicts, 96 

Magendie's  findings,  38 
Mar  me  and  oxydimorphine,  38 
Mechanism,    essential,    of    addic- 
tion disease,  41 
of     narcotic     drug     addiction 

disease,  36 
of  protection,  47 


164) 


INDEX 


Medication,  ignorant  or  unavoid- 
able,  and   drug  addiction, 
27 
opiate,    indispensable    and    le- 
gitimate, 116 
"  specific,"  fallacy  of,  56 
Misunderstanding       of       addict, 
cause  of  early  failures  in 
treatment,  5 

"  Narcotics,"   definition  of  term, 

114 
Need,  drug,  minimum  daily,  66 
of  the  hour  in  study  of  drug 

addiction,  130 
narcotic  drug,  and  mental  and 
muscular  work,  69 

Observation  in  Bellevue,  sixteen 
months,  day  and  night,  3 

Observations  on  physical  or 
body  reaction,  32 

Opiate,  withdrawing,  simply  one 
stage,  92 

Opiates,  and  their  unique  prop- 
erties, 116 

Organizations,  medical  duty  of, 
104 

Origin  of  addiction,  25 

Oxydimorphine  and  Marme  the- 
ory, 38 

Panaceas,  search  for,  56 

Patients,  intelligent,  and  the 
avoidance  of  complica- 
tions, 78 

People,  eminent,  and  drug  addic- 
tion, 27 

Philanthropy  and  its  opportu- 
nity, 135 

Physician,    average,    is    inexpert 
in  handling  addiction  dis- 
ease, 108 
suffering  from  drug  addiction, 
viewpoint  of,  146 

Physicians,  honest,  and  their  re- 
sponsibility, 103 

Pilocarpine,  use  of,  50 

Practice,   legitimate   medical,   95 


Practitioner,  honest,  and  con- 
trol of  illicit  drug  traf- 
fic, 123 

Principles,  basic,  of  addiction- 
disease  handling,  65 

Problem,  drug,  still  unsolved,  5 
of    drug     addiction,    ultimate 

solution  of,  108 
of  the  care  of  the  innocent  and 
worthy  addict,  129 

Profession,  medical,  attitude  of, 
50 

Prostitution  and  *'  white-slav- 
ery," 125 

Protection,    bodily,    against   opi- 
ate, 42 
mechanism  of,  47 

Pulpit  and  press,  duty  of,  135 

Purgation,  excessive,  warning 
against,  81 

Purpose,  chief,  of  most  lay  and 
medical  workers,  96 

Questions  that  confront  the 
American  people,  136 

Reaction,  normal,  stage  of,  29 
to     therapeutic     and     toxic 
doses,  29 
of  drug  addicts  to  therapeutic 
agents,  68 
Reduction,  enforced,  below  bodily 
need,  dangers  of,  69 
slow,  51 
References    to    recent    literature, 

39 
Regulation,    legislative    and    ad- 
ministrative, 105 
of   intervals   of   narcotic   drug 
administraction,  66 
"  Relapses "    and    production    of 

antidotal  substance,  45 
Report,  1915,  of  New  York  Dept. 
of  Correction,  72 
Preliminary,  of  Whitney  Com- 
mittee, 110 
Responsibility  for  drug  addiction 
laid  on  medical  profession, 
102 


INDEX 


165 


Restoration    of    drug    addict    to 
health,  83 

Side,  personal,  of  drug  addiction, 
137 

Solution   of   drug  problem,  ulti- 
mate, 108 

Stage   of   study,   preliminary   to 
withdrawal,  63 
preliminary,   abnormalities   in, 
83 

Stages  of  addiction  development, 
29 

Stool,  "  typical,"  of  Towns  treat- 
ment, 79 

Study,    clinical    and    laboratory, 
lack  of,  91 
of    patient,    essential    as    pre- 
liminary   to    withdrawal, 
63 

Substance,    antidotal,    to    opiate, 
and  bodily  protection,  42 

Suffering,  physical,  and  drug  ad- 
diction, 20 

Survey  of  the  situation,  122 

Terms  that  should  be  eliminated, 
9 

Testimony  of   Whitney   Commit- 
tee,  deductions   from,    134 

Theories,  author's  wrong,  12 

Tolerance,  explanation  of,  38 
increased,  stage  of,  30 


Traffic  in  narcotic  drugs,  illicit, 

103 
Treatment,    importance   of   regu- 
lating   intervals    of    nar- 
cotic  drug  administration 
in,  65 

rational,  of   addiction   disease, 
61 

so-called  specific,  55 

specific,   author's   disbelief   in, 
80 

"  Underworld "  and  desperate 
necessity  of  addict,  28 

Use,  legitimate,  of  narcotics  in 
peace  and  war,  114 

Valenti's  studies,  26,  38 
Veterans,    Civil    War    and    drug 

addiction,  24 
Views,    personal    and    legal,    of 

drug  addiction,  137 

Whitney     Committee.     Hearings, 

testimony  of,  107 
Withdrawal  accompanied  by  use 
of  various  drugs,  51 
forcible,  and  suicide,  53 
stage  of,  62 
sudden,  53 
symptoms,  35 
Withdrawing    of    opiate    simply 
one  stage,  92 


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The  narcotic  drug  problem. 


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